5th AIDS MEDIUM TERM PLAN MID-TERM REVIEW

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Mid-term Review 0|Page

TABLE OF CONTENT Table of content Abbreviations and Acronyms Acknowledgments Summary of Key Recommendations Organization and Conduct of the External review of the AMTP5 1. Introduction and objectives of the Review 2. Two evaluation teams, one goal, one report 3. Evaluating a common strategic plan 4. Process 5. Report production I. Epidemiology of HIV: the growing burden I.1 Increased number of new HIV diagnosed cases I.2 Increased HIV prevalence among MSM and PWID I.3 HIV prevention among MARPs: coverage remains an issue II. Strategic information II.1 Mapping and counting key populations 1.1 risk assessment 1.2 Limited analysis and access to IHBSS 1.3 Local government resistance to data sharing 1.4 Coverage of IHBSS surveillance among people who inject drugs 1.5 Reaching the highest risk individuals through local mapping 1.6 Monitoring HIV among pregnant women 1.7 Surveillance in closed settings 1.8 Population size estimates II. 2 Assessing outcome and impact: Moving beyond HIV prevalence.

2.1 Monitoring and assessing outcome and impact: 2.2 HIV incidence 2.3 Mortality 2.4 Morbidity due to opportunistic infections 2.5 Improving analysis presented in STI case reports II. 3. Monitoring retention and quality across the cascade of health services 3.1 Bringing those in needs to Treatment 3.2 Monitoring retention of pre-ART patients 3.3 Tracking the cascade for most-at-risk populations 3.4 Monitoring health facilities’ adherence to services protocols 3.5 Putting it all together: Continuous quality improvement 3.6 Human resources for strategic information

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III. Continuum of Prevention, Care and Treatment III. 1. Prevention packages for Key Populations 1.1 Policies and Strategies for prevention, care and treatment 1.2 Prevention packages for Key Populations 1.3 Condom promotion and distribution programmes 1.4 Sexually transmitted infections 1.5 Availability, accessibility, acceptability and quality of STI/HIV services 1.6 Sexual and reproductive health and rights 1.7 Populations living in confinement III. 2. HIV Testing and Counselling 2.1 Promotion and uptake of HIV Testing and Counselling 2.2 Coverage and access

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2.3 Quality of the HIV testing and counselling process 2.4 Counselling women in the post-partum and children III.3 HIV testing and Laboratory Support 3.1. HIV testing and testing facilities 3.2 Reference laboratories 3.3 Nuclear Acid Testing (NAT) and CD4 testing 3.4. Blood Safety 3.5 HIV testing algorithm used for Blood Screening+ 3.6 HIV testing of neonates 3.7 HIV testing for Key Populations and HIV HCT services 3.8 MSM not returning to receive results (loss to follow up) 3.9 Regulation, quality assurance and quality systems 3.10 Quality assurance mechanisms 3.11 Test kits procurement IV. Enhance policies for scaling up HIV programs IV.1 Lack of progress in Strategic information IV.2 Ensure more investment on HIV and on prevention among MARPs 2.1 AIDS response underfunded 2.2. Resources should be allocated more strategically IV. 3 Progress in laws, policies and guidelines 3.1. Promising development but unfinished agenda 3.2 Discrimination and social stigma V. Expand capacity of PNAC V. 1 Capacity of PNAC strengthened to perform its functions 1.1 Human and financial resources 1.2 PNAC structural dysfunctionality 1.3 Strengthening PNAC secretariat V.2. Interagency coordination and collaboration strengthened 2.1 The National Monitoring and Evaluation System VI. Strengthening Capacities of Local Governments and Communities

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VI. 1 Strengthening Local Governments for Responses 1.1 Regional AIDS Assistance Teams 1.2 Local HIV/AIDS Council 1.3 LGU Ownership of HIV Response VI. 2 Strengthening Communities for HIV Responses 2.1 Partnerships CSO 2.2 Enhancing Network of the National HIV and AIDS Response Annexes 1. List of team A&B members 2. Opinion survey about PNAC among key stakeholders 3. Documents reviewed and data sources 4. Proposed PNAC organigrams and Terms of reference for Working Committee on Localization & Convergence 5. Research issues 6. Key informants

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ABBREVIATIONS AND ACRONYMS AIDS Registry AMTP ANC ART ARV ASP BC BCC BSF CHD CHOWs CSO CUP DepEd DILG DOH DOLE DSWD EE EPP/Spectrum FBO FGD FSW FFSW GAD GARPR GFATM GF R6 HACT HBC HCT IDU IEC IHBSS KP LAC LGU MARPs M&E MDGs MBD MSM MSW MTCT NASPCP NCHFD NCR

Philippine HIV and AIDS Registry AIDS Medium-Term Plan Antenatal clinic Anti-retroviral Therapy Anti-retroviral AIDS Society of the Philippines Blood Center Behaviour Change Communication Blood Services facility Centre for Health Development Community Health Outreach Workers Civil Society Organization Condom Use Programme Department of Education Department of the Interior and Local Government Department of Health Department of Labor and Employment Department of Social Welfare and Development Entertainment Establishment Estimation and Projection Package and Spectrum (Software) Faith-based Organization Focus group discussion Female Sex Worker Freelance Female Sex Worker Gender and Development Global AIDS Response Progress Report Global Fund to Fight AIDS, Tuberculosis & Malaria Global Fund R6 HIV/AIDS Core Team Home -based care HIV counseling and testing Injecting Drug User Information, Education and Communication Integrated HIV Behavioural and Serologic Surveillance Key population Local AIDS Council Local Government Unit Most-at-risk populations Monitoring and Evaluation Millennium Development Goals Mobile Blood Donation Men who have Sex with Men Male sex worker Mother-to-child transmission National AIDS and STI Prevention and Control Program National Center for Health Facilities Development National capital region 4|Page

NEC NEDA NGO NRL NVBSP OFW OI OOP OSHC PAFPI PBC PDOS PE PEP PhilHealth PICT PLHIV PNAC PMTCT PWID RAAT RFSW RHWC RITM SHC SOP STI TB TCS TG TTI TWG UNGASS UA VBD VCT

National Epidemiology Centre National Economic Development Authority Non-Governmental Organization National Reference Laboratory National Voluntary Blood Services Program Overseas Filipino Worker Opportunistic Infection Out-of-Pocket (expenditures) Occupational Safety and Health Center Positive Action Foundation of the Philippines Philippine Blood Center Pre Departure Orientation Seminar Peer educator Post exposure prophylaxis Philippine Health Insurance Corporation Provider initiated counseling and testing People living with HIV Philippine national AIDS Council Prevention of mother to child transmission People who inject drugs Regional AIDS Action Team Registered female sex workers Reproductive Health and Wellness Center, see SHC Research Institute for Tropical Medicine Social Hygiene Clinic Standard operating procedure Sexually transmitted infection Tuberculosis Treatment care and support Transgender Transfusion transmittable infection Technical Working Group United Nations General Assembly Special Session on HIV/AIDS Universal access to HIV prevention, treatment, care & support Voluntary Blood donation Voluntary counseling and testing

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Acknowledgements First and foremost, the Evaluation Team wishes to express its thanks and words of support to People Living with HIV in the Philippines. They confront HIV with great courage and resilience inspite of the difficulties they encounter as a result of sparsely available care and treatment services and unabated stigma and discrimination.

The Evaluation Team wish to extend their thanks to the authorities of the Philippines National AIDS Council and the Department of Health for having invited them to review the accomplishments, shortcomings and opportunities for further progress of the national response to HV and Sexually-transmitted diseases. The Team would also like to acknowledge warmly the very efficient members of national and external secretariats who supported its work managerially, administratively and technically with great efficiency, commitment and courtesy.

They played a critical role in assembling documents, analysing data, securing site visits and appointments and making sure the Evaluators were there and returned safely and on time.

Equally important to the conduct of this review were the many health, social and other workers who, at all levels of governmental and non-governmental systems, took precious time out of their very busy schedules to meet with the team and provide them with information while keeping an eye on the ways things were routinely working in their office, crowded clinic, laboratory or other facility.

The Evaluation team was deeply impressed by the competence and dedication of first-line actors who, since the emergence of HIV in the Philippines, have borne the brunt of the national response to HIV and STIs, often in under-staffed, under-funded and sub optimal physical environments. Health care providers, counsellors, peer educators, community-based workers and non-governmental organisations deserve recognition for playing a pivotal role in the extension of services to key populations. They should be credited for saving the lives of many women, men and children infected or affected by HIV while improving their quality of life.

Finally, the Evaluation Team wishes to convey its heartfelt words of support to communities, families and individuals who confronted two major natural disasters, which severely affected the Philippines. While the evaluation was unfolding, the deadly Bohol earthquake and Typhoon Haiyan (Yolanda) took a large toll on lives, properties, basic needs and means of survival on the population of the eastern coast of the Philippines. Reportedly, services extended to People Living with HIV in the disaster areas were severely affected and the sustained provision of care and treatment services to survivors was seriously hampered. The Team extends its condolences to the affected families and wishes their communities to recover promptly. It sincerely congratulates rescue staff for their courageous and relentless work on the ground in the disaster areas.

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Summary of Key Recommendations Below is a capsule summary of key recommendations of the Review, selected according to their importance and expanded in the body of the report.

To follow up on the recommendations, the Review team proposes to set up a Monitoring Committee comprising of representatives of the parties that participated in the development of the AMTP5.

The panel will critically look at validity of the recommendations, their priority, and their accuracy, and draw up an action plan with a budget to be presented to the PNAC Board within the next 3 months.

I. Epidemiology of HIV: the growing burden I.3 HIV prevention among MARPs: coverage remains an issue In order to improve service coverage among Most at risk populations (MARPs), there is a need to intensify outreach services and community mobilization. There is also a need to reorient service provision and ensure so that it is accessible and acceptable to youth and MSMs. Targeting needs to be focused on areas where most HIV infections are coming from both geographically (National Capital Region, Metro Cebu, and Davao) and in terms of key affected populations (MSMs and PWID). Advocacy activities geared towards increasing investments of local government units need to be scaled-up especially in terms of funding provision for HIV prevention activities (behavioural change communication, diagnostic/medical/commodity supplies), human resource augmentation (medical technologists, counsellors, peer educators), and health facility enhancement. There is also a need for continuous engagement of community-based organizations to increase demand of services as well as collaboration with the private sector with regard to HIV counselling and testing strategy. A policy on HIV prevention, that includes condom promotion and harm reduction, including needle exchange, should be a priority for PNAC and DOH.

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Strategic information

II.1. Mapping and Counting Key Populations 1.2. Limited analysis and access to IHBSS The NEC should make widely available complete technical reports from IHBSS surveillance rounds accompanied by actionable factsheets within 6-12 months after the completion of each surveillance round, through online publication, local briefings and distribution of hard copies. A thorough description of the methods applied, samples obtained, analytic techniques, and confidence intervals should be included in all materials. The current IHBSS Technical Working Group has not provided effective oversight regarding dissemination to date. Thus, scientific oversight should be carried out by the leadership of the NEC (NCDPC) and/or the Office of the Secretary of Health (which oversees NEC), jointly with an expert 7|Page

panel, feeding early results onto the Department of Health, Local Governments and the PNAC Executive Committee, given the importance of IHBSS data to HIV programming.

1.3. Local government resistance to data sharing Ahead of IHBSS surveillance rounds, NEC should enter into a formal agreement (e.g., via an MOU) with local governments selected to participate, stating that national and local findings will be made publicly available through technical reports, factsheets and other media, and made available online, regardless of what the results show. Civil society should be made a part of this process via national and local AIDS councils so that their voices may be heard.

I.4. Coverage of IHBSS surveillance among people who inject drugs Building on the Rapid Assessment, regular assessments to identify the presence of significant PWID populations should be conducted in urban areas that meet objective criteria (such as all Category A sites) nationally. Additional criteria should be established to determine under what circumstances findings from these PWID vulnerability assessments should lead to establishing a new IHBSS site for PWID. The NEC’s guidelines on rapid assessment of vulnerability should be enhanced to ensure that the assessments systematically gather and triangulate data from hospital emergency departments, substance abuse rehabilitation centers, police and local NGOs working with drug users in order to identify evidence of injection drug use.

The National Epidemiology Center (NEC) should make widely available complete technical reports from IHBSS surveillance rounds accompanied by actionable factsheets within 6-12 months after the completion of each surveillance round, through online publication, local briefings and distribution of hard copies. A thorough description of the methods applied, samples obtained, analytic techniques, and confidence intervals should be included in all materials. The current IHBSS Technical Working Group has not provided effective oversight regarding dissemination to date. Thus, scientific oversight should be carried out by the leadership of the NEC (NCDPC) and/or the Office of the Secretary of Health (which oversees NEC), jointly with an expert panel, feeding early results onto the Department of Health, Local Governments and the PNAC Executive Committee, given the importance of IHBSS data to HIV programming 1.5. Reaching the highest risk individuals through local mapping To guide more effective targeting of prevention, data from IHBSS should be used to generate local maps that identify those locations (establishments and street locations) with the highest concentration of highest-risk behaviors, including patterns of low condom use, high number of partners and frequent needle sharing, and overlapping risk (MSM-PWID, FSWPWID). Organizations carrying out outreach, including social hygiene clinics and needlesyringe programs, should be trained on how to use this information to target individuals at highest risk for HIV infection and transmission.

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1.6 Monitoring HIV among pregnant women in areas with heavy HIV burden Estimates of levels of HIV infection in antenatal women in cities where high levels of HIV infection (e.g., at least 10%) have been detected in most-at-risk populations should be incorporated into local and national surveillance systems by either (1) strengthening routine screening among pregnant women in these areas to bring HIV testing coverage to at least 90%; or (2) conducting periodic antenatal surveillance studies at selected sites in these areas every 1-2 years.

1.7 Surveillance in closed settings Formative research to characterize MSM and injection drug use risk behaviours in prison populations should be carried out to determine the need for biological and/or behavioural surveillance. Criteria for selecting sites for the formative assessment should be established and should include consideration of (1) number of inmates and (2) geographic proximity to Category A areas. These data should be used to design, implement and monitor HIV and TB prevention, care and treatment in prisons.

1.8 Population size estimates Dissemination of population size estimates for most-at-risk populations in Category A (and potentially Category B) areas should be improved by (1) documenting the specific methods employed and findings (including uncertainty ranges of the estimates) from size estimation exercises in technical reports within 6 months of completion; and (2) Providing technical support and capacity building to improve their understanding and use of size estimates in prevention activities.

Size estimation using the multiplier method should be integrated into all future IHBSS surveillance rounds for MSM, freelance and registered FSW and PWID, using services and/or unique object multipliers. Given the wide confidence intervals typically associated with these estimates, multiple multipliers should be used for each population as possible. Methods and findings from multiplier estimates should be documented as in the preceding recommendation

II.1. Assessing outcome and impact: Moving beyond HIV prevalence.

2.1 Monitoring and assessing outcome and impact There should be a strengthening of epidemiological surveillance, the application of new laboratory technologies along with greater dispersion of existing technologies (e.g. rapid tests for HIV and STIs, CD4 count, Viral Load), stronger data linkages from individual entry into active prevention programmes, HIV testing and counselling, enrolment in the care and treatment continuum, and eventually through the end of life, as well as improvements in social, behavioural and economic determinants of health and well-being.

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2.2 HIV incidence The national surveillance system should incorporate measures of HIV incidence, including two strategies. First, incidence assays should be applied to specimens from IHBSS studies to estimate incidence among key populations, potentially pooling samples across nearby cities to obtain sufficient sample size.

2.3 Mortality NEC should develop methods to regularly (every 1-2 years) cross the HIV/AIDS registry with the national civil deaths registry in order to capture (1) deaths among people with HIV, due to any cause; and (2) deaths attributable to HIV. Analysis based on these combined data should be developed to improve understanding of patterns in mortality (demographic and risk characteristics, relation to late diagnosis and treatment characteristics) at the national and local levels, with the aim of improving the effectiveness of care and treatment.

2.4 Morbidity due to opportunistic infections AIDS registry reports should summarize rates and opportunistic infections and characteristics of PLWH who have OIs. Summaries of trends in the rate of opportunistic infections should be made available to treatment hubs with support in using these trends to improve treatment effectiveness.

2.5 Improving analysis presented in STI case reports Analysis presented in the SSESS reports should be expanded to include breakdowns by age, sex and type of facility. The analysis should be made more accessible and actionable by including figures illustrating trends, characterizing STI risks and vulnerability, and making the reports available to health practitioners and researchers online.

II. 3 Monitoring referral, retention and quality across the cascade of health services 3. 1. Bringing those in needs to Treatment Standardized mechanisms for referral should be accompanied by standardized mechanisms to routinely monitor that referrals have actually resulted in linkage between services (such as program registers and summary reports), using a unique identifier such as the SACCL code. Procedures for tracking referrals should be incorporated into existing SOPs and training and supportive supervision should ensure their use. Data on trends over time in the percentage of referrals that are realized—from outreach to testing, testing to care, and care to treatment—should be made available to social hygiene clinics, treatment hubs and TB treatment centers and DOTs facilities. Procedures for personnel to meet periodically (e.g., quarterly) to review these data and collaboratively identify measures to improve referrals should also be established. A data field for source of referral into testing should be added to the HIV and AIDS registry form in order to capture referrals from TB patients, antenatal care and private testing facilities.

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3.2. Monitoring retention of pre-ART patients Linkage to and retention in care should be routinely monitored either through routine reporting using the new Form B, or by establishing facility-level registers that capture sufficient data on enrolment and follow-up (including SACCL code) to allow tracking of individuals over time. Additionally, standard care and treatment reports at the facility and national levels should include summaries of patients who are awaiting eligibility screening, those in pre-ART and those in ART. Cohort-based measures of retention in both care and treatment should be developed and procedures established for data review and decisionmaking to ensure that the data are used regularly (e.g., monthly) for program improvement.

3.3. Tracking the cascade for most-at-risk populations At national and facility levels, trends in retention and loss-to-follow-up for MSM, FSW and PWID should be routinely monitored through standard reports, with procedures for regular review and decision-making based on findings. Analysis to generate these trends would be most easily generated at the national level, given that national-level databases would allow the analysis to account for transfers between facilities.

3.4. Monitoring health facilities’ adherence to services protocols The level of training and supportive supervision to help HIV testing and treatment facilities adhere to services protocols should be strengthened through inception and periodic inservice refresher training activities centred around existing Standard Operating Procedures.

3.5 Putting it all together: Continuous quality improvement A single report should be developed for use at the LGU level providing data and trends in indicators of program quality and effectiveness, such as referrals into care and treatment, retention in care and treatment, and morbidity. A standard procedure should be developed to ensure regular review (e.g. quarterly) of the quality measures by individual health facilities (social hygiene clinics, treatment hubs, TB facilities) and local HIV collaborative HIV teams in order to facilitate early detection of problems and collaborative solutions. The national level (NEC and PNAC) can support these efforts by providing guidance, training and supportive supervision for the review and interpretation of the quality indicators and problem-solving process.

3.6 Human resources for strategic information: essential, under-resourced and vulnerable The bulk of this work would be better accomplished by computer programs, with manual review reserved for following up on those inconsistencies that are automatically detected.

Such validation checks could be automated at low cost. Optical Character Recognition (OCR) technology should be introduced to automate the data entry process and reduce data entry error. This would require an initial investment, but would appear quite justified given the high volume of work involved.

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III.

Continuum of Prevention, Care and Treatment

III. 1 Prevention packages for Key Populations Specific efforts should be made to address the bottleneck prohibiting the full implementation of the national guidelines at local level. The comprehensive packages for key populations should be re-assessed, a minimal package of prevention interventions should be defined and accompanied with a concrete quality assurance mechanism.

The development of a master health sector plan should be considered, maximizing the utilization of the existing health infrastructure, social hygiene clinics in particular, to mainstream evidence informed and rights based prevention services to key populations. In addition, building staff capacity at SHCs to expand its scope of services in order to cover all key populations and establish a stronger partnership with NGOs and CBOs working with key populations. Local innovation of service delivery models should also be encouraged and good practices documented for sharing and replication.

1.2 Prevention packages for Key Populations The national surveillance for PWID should be strengthened by covering more of the National Capital Region (NCR) sites (Malate, Quezon City in particular) to detect epidemics early, while continuing to monitor the high level of needles/syringe sharing behaviour. Given the high HIV prevalence already detected in Cebu and Mandaue, it is urgent to initiate community based pilot projects of needle and syringe exchange, in line with the instruction of the Dangerous Drugs Board in collaboration with all local stakeholders in selected cities.

MSM must be engaged more actively in delivering services, and peer outreach. Prevention activities must be adapted to the diversity of MSM sub-populations, including those living with HIV, and address sexual health needs through a variety of approaches and combinations of interventions best suited to the specific needs, demands and capacities of these subpopulations. Innovative use of mass and targeted media, including the internet and cell phone, should be integrated components in the delivery of prevention messages, health promotion and social support services. Commodities, such as condoms and lubricants, should be readily available and widely promoted. Prevention activities should be strengthened using a variety of channels and encouragement of local innovations, in locations where high risk behaviour may occur and include structural interventions. These should be included in a minimal package of preventive services, with strong linkages with HTC and ARV. Prevention Interventions for sex workers should be targeted/adapted based on local sex work patterns, local STI prevalence and policy environment. Social hygiene clinics should be better used to improve the services for registered sex workers; building partnership with sex work NGO and CBO’s to extend the scope of quality services to freelance female sex workers, male sex workers and transgender people. Interventions should incorporate inputs of sex workers and their community into how to make services user-friendly.

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A Transgender specific programme should be created in consultation with transgender community representatives. Other project areas should also be more active in identifying transgender peer leaders as peer educator to initiate partnership between health services and transgender community. Health providers should receive orientation and sensitization on transgender issues and on how to stimulate the participation of transgender people in peer outreach and in the delivery of services.

1.3 Condom promotion and distribution programmes A national condom strategy should be developed. Policies on correct and consistent condom use in sex work settings should be in place and the policies should be supportive of community empowerment for the work norm ‘no condom, no sex ‘. Condoms should be made available through a variety of channels: free of charge distribution, condom social marketing approach and involvement of private sector promotion. Condoms should be easily available and accessible for registered sex workers based in sex venues. Outreach activities should be scaled-up to offer free distribution of condoms and water-based lubricants to freelance female and male sex workers, MSM, PWID and transgender people.

1.4 Sexually transmitted infections Particular efforts should be made to improve the quality of STI screening among key populations. To this end, more systematic and optimal standards of clinical and biomedical diagnostic procedures should be enforced by periodically trained and retrained staff.

1.5 Availability, accessibility, acceptability and quality of STI/HIV services Greater investment in Peer Education and other service delivery models apart from the Social Hygiene Clinic should be considered. Skills of peer educators should further be enhanced through regular training and supportive supervision from site implementation officers. Appropriate peer educators should be recruited, including adequate number of peer educators. Peer educators should perform micro planning to ensure systematic approach of reaching key population. They should have appropriate monitoring tools to track number of KP reached and repeat visit, services provided and required follow up. Develop training modules and job aides for peer educators should be developed and standardized.

There is a need for a designated person at the national level to track stock outs of essential HIV prevention commodities. Guidelines on tracking stock outs could be provided by the Global Fund procurement focal point at the national level.

It is essential to maintain or improve coordination between SHC and NGO Peer Educators.

Regular meetings should be held to discuss targets and issues on quality of services. The needs of MSM and PWID and acceptability of current services should be assessed, seeking suggestions on the best way to increase access and acceptability of services. The conduct of exit interviews of Key Populations using services and the conduct of Focus group Discussions among Key Populations not using these services should result in the design of new service delivery models aimed at to increasing access and use of services by MSM. Minimum standards of quality of service should be formulated along with monitoring indicators. The 13 | P a g e

physical infrastructure of venues where services are provided (SHC and others) must urgently be improved.

1.6 Sexual and reproductive health and rights (including reproductive choices), contraception, fertility enhancement The following SRH services should be provided on-site or by establishing functional referral mechanisms: Family planning and contraceptive counselling; (promote dual protection for pregnancy, STI and HIV); ensure availability of condoms and if possible contraceptives at service delivery points for SW and PLHIV+; orientation of women to reproductive choices, safe pregnancy, abortion and post-abortion care and reproductive tract cancer screening (e.g. cervical, ano-rectal and prostatic cancers); and counselling on hormone use and referral to other gender enhancement practices for transgender people.

1.7 Populations living in confinement It is recommended that a formal agreement between the prison administration and the Department of Health be formally approved in the form of a joint policy or a memorandum of understanding, accompanied by Standard Operating Procedures for the management of HIV within prisons and after transfer between prisons, addressing as well best practices in HIV/STI prevention and care and related supplies of medicines and commodities in detention facilities. It is further recommended that such procedures also cover the referral of inmates treated for HIV upon their release from prison so as to ascertain the continuum of care and prevention once they return to their communities. Civil Society Organizations ad more generally NGOs should be prompted and supported to play a key role in enhancing continuity of prevention, care and treatment for people in and out of jail.

There is a need to document current practices in rehabilitation centres where STI and HIV intervention activities have been initiated. Such evidence could inform future policy and practices that could be generalized to all rehabilitation centres (private and government run).

The on-going STI and HIV related interventions in some rehabilitation centres need to be coupled with capacity building among staff, in particular on the handling of residents diagnosed with these conditions.

Given the large and growing number of drug dependent residents outreach and open rehabilitation services providing psycho-social support should be explored and enhanced.

The high relapse rate after discharge from rehabilitation centers should be taken into consideration in the evaluation of the design, implementation and effectiveness of the interventions and support services.

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III. 2. HIV Testing and Counselling 2.1 Promotion and uptake of HIV Testing and Counselling Peer educators (PEs) require standardised training with skills rehearsal that enables them to ask if people have had a test, to explore reasons for not having had a test and to be able to challenge the client’s thinking and encourage them to take the test. Similarly, these training needs to ensure PEs also to sensitively enquire if people collected their HIV test results and without requesting to know the result) explore and challenge the reasons for non-return results.

2.2 Coverage and access Expanding the available range and type of HTC models is key to improving coverage, access and entry into care. Innovative service models should be field tested such as private–public partnerships where sharing of resources such as counsellors provided by NGO or government funding with private service providers identified as being favoured by key populations. Additionally, the expansion of service hours and the employment of different models of pre test counselling that require less time should be considered to alleviate congestion and improve both future increased demand for HTC and improve the quality of HTC in Social Hygiene Clinics. Innovative service implementation should continue, for example the referral to treatment hubs and enrolment of MSM who are community VCT clients after provisional diagnosis with receipt of two reactive results, from two different tests. Such approaches should be applied and replicated where these services can be monitored for compliance with DOH service standards. In order to improve access to necessary health care to minors it is imperative that there is immediate, strengthened advocacy for the revision of Philippines AIDS Law in respect to testing of minors.

2.3 Quality of the HIV testing and counselling process There is a need for DOH to develop a HTC quality monitoring and management system and assume a strengthened regulatory role. The HTC quality management program would assume responsibility for standardising pre and post test counselling training courses, ensure standard operating procedures are available for different types of service models (e.g. mobile or community-based VCT), and ensure standard medical record documentation occurs across government, non government and private HTC services. It is further recommended that in order to ensure appropriate, explicit and consistent health messages are delivered by counsellors, that counselling tools be developed that are specifically oriented to the needs of specific key populations. There is an urgent need to send out a circular or memorandum to all HTC service providers alerting them to their legal and ethical duty of care to check results before provision to clients to ensure that correct result has been provided to the client. Additionally, it is essential that HTC providers realize that they need to check client understanding of the results and implications for transmission prevention, and to facilitate linkages to treatment and care. There is also a duty of care providers to assess client’s ability to cope with an HIV positive result and where necessary address threat of risk of harm to self or others.

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2.4 Counselling women in the post-partum and children Depression not only reduces the quality of life of infected women but can contribute to poor treatment adherence, and to an inability to bond with, and care for, their newborn baby. It is imperative that counsellors are made aware of common signs and symptoms of depression and the phenomena of post partum depression, and understand the importance of referring to appropriate mental health professionals. It is further recognized that it is important to increase the male partner’s involvement in antenatal and postnatal care. Partners should be invited to consultations where appropriate and feasible. Counsellors require specific training that enables them to offer family or relationship support.

Counsellors and ancillary support workers working with parents and children require specific training addressing the issues of disclosure, preparation of children for clinic and hospital visits, and how to provide age appropriate counselling for HIV positive children and adolescents and their siblings.

III.3 HIV testing and Laboratory Support 3.2 Reference laboratories In order to accelerate the availability of confirmed results and reduce poor return for test results, it is critical that the planned serial rapid test validation study proceeds as soon as possible. It is also critical to assess the available quality systems to support the implementation of a three rapid test algorithm for screening and confirmatory with immediate results in non-laboratory facilities such as SHC and community based HTCs as soon as possible. As an interim until the serial rapid test algorithm can be implemented, delays in provision of results should be shortened by extending the model service currently employed by community based services whereby the referral to treatment hubs and enrolment of MSM who are community VCT clients occur after provisional diagnosis with receipt of two reactive results, from two different tests. This approach should be replicated only where these services can be fully monitored for compliance with DOH in order to support quality testing. There is an urgent need to address the gaps in quality assurance of HIV testing. To this end, licensing, regulation of test kits, participation in EQAS and training should be considered. There is also a need to develop national training elements around the management and procurement of test kits and reagents. It is further recommended that the NRL extend EQAS schemes from one HIV distribution to two HIV distributions per year.

3.3 Nuclear Acid Testing (NAT) and CD4 testing A three rapid test algorithm for screening and confirmatory testing with immediate results should be considered during the validation of the new HIV Testing Algorithm. The available of quality systems to support the implementation of a three rapid test algorithm for screening and confirmatory test with immediate results in non-laboratory facilities such as SHC and HCT should be explored.

CD4 count technology and operating skills should be scaled-up to match the expected increase in HIV testing demands, particularly as the criteria for enrolment in care change.

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IV.

Enhance policies for scaling up HIV programs

IV. 1 Lack of progress in monitoring the response Recommendations 1.1 PNAC will need to redefine the role and composition of its Board in order to be more responsive to the concentration of the HIV epidemic among MSM and IDUs and to fill the gaps in the response pertaining to these groups. The M&E key function of PNAC secretariat should be matched with an M&E unit with support staff and budget.

The M&E framework of AMTP5 needs to be revised and adapted to capture the HIV program activities of sectors and agencies at central and local levels. PNAC should be in a position to fund catalytic activities in the sectors directly relevant to the new HIV epidemic realities and, through MOUs, follow up the implementation of sectoral activities. At local level, PNAC should adopt a phased approach by extending direct M&E support to LACs and LGUs in selected priority settings. Based on city investment plans, M&E templates should be developed for LACs and LGUs. The M&E links between LACs and PNAC should be strengthened.

IV. 2. Ensure national investment commensurate with HIV cases and more targeted to the groups most at risk 2.1 and 2.2 Resources should be allocated more strategically PNAC, DOH and development partners should increase coordination and harmonization to maximize available resources. Gains in efficiency should be made by reducing program management cost and by re-allocating funds to prevention programs for MSM and PID. More advocacy and resource mobilization should be undertaken by PNAC & DOH to increase domestic investment, particularly within government sectors and to reduce dependency on external sources. The oversight role of the Philippine Congress on the National HIV response that define the PNAC budget should be strengthened - with PNAC reporting once a year about the results achieved. A system to ensure financial accountability of all implementing partners must be put in place. The role of CSOs in calling for PNAC accountability in resource utilization should be encouraged as such a process promotes transparent financial performance by government, which would help in mobilizing further resources. Similarly, accountability of CSOs in the utilization of funds provided to them should be improved.

National spending assessments should be a priority for PNAC to help guide implementation of AMTP5. Spending assessments should also be conducted at the City level to allow for a more in-depth analysis of AIDS expenditure and support strategic policy and programme planning. NASA assessments, at city and national level, should be made public to ensure accountability and to identify gaps in resources in city investment plans. The NASA findings should be more broadly disseminated by PNAC among key national and international stakeholders to ensure their use.

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IV. 3 Progress in laws, policies and guidelines to support comprehensive HIV programs 3.1. Promising development but unfinished agenda PNAC should play a more active role to disseminate new HIV policies and guidelines and to facilitate their implementation. In order to strengthen PNAC’s leadership and guidance role, “HIV champions” from private and public sectors should be engaged to increase visibility of the HIV agenda. The passage of the new HIV bill and other related laws should be the opportunity for organizing systematic advocacy. While the new HIV law is pending, PNAC & DOH should prepare a national HIV prevention policy to include promotion/provision of commodities such condoms and needles. PNAC should proactively assist and coordinate in developing HIV ordinances that will remove obstacles to effective local HIV programs (e.g. police raids). PNAC and civil society organizations should also give more central support to LGUs who are experiencing law enforcement abuse, arising from arbitrary interpretations of existing policies.

3.2 Discrimination and social stigma Fighting stigma and discrimination against hard to reach populations and PLHIV is a critical enabler and concerns all stakeholders and sectors. PNAC and DOH should continue to empower MARPs and build the capacities of their networks. The health sector, both public and private, has a particular responsibility to protect the right of PLHIV to confidentiality.

Shared responsibility should be encouraged and engaging accredited PLHIVs as counselors should be a first step in this direction. Human rights literacy training of PLHIV should be an integral component in community level mobilization. PLHIV networks should educate their members about their rights, especially about HIV testing and confidentiality. Promotion of acceptance of PLHIV and advocacy on non-discrimination should be part of media campaign, school education curriculum, community and work-based initiatives. The Commission of Human Rights should be officially designated as the locus for the handling HIV-related human rights violations and complaints.

V.

Expand Capacity of PNAC

V. 1 Capacity of PNAC strengthened to perform the function as the central advisory, planning and policy making body of the national response.

1.1 Human and financial resources Funds for PNAC should be increased to a level that will ensure core budgets for the operational plans of the working committees. Operational planning should be a prerequisite to fund allocation. PNAC should sub-allocate funds to lead/implementing agency per working committee for the direct execution of operational plans targeted to move towards achievement of strategic objectives. Working committees should report regularly to the

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ExeCom; information generated from reports should be consolidated in periodic reports and shared among all Council members and to the general public.

Member agencies/organizations should take the lead in implementing an operational plan in the achievement of the strategic objectives and just reports to the ExeCom through the Secretariat; Secretariat designs and rolls out an M&E plan anchored on the operational plans where information generated from committee reports are consolidated & shared systematically; and PNAC Secretariat performs its core functions to oversee, coordinate & extends technical support when necessary in the execution of the AMTP5 as well as to monitor the response to HIV. 1.2 PNAC structure The Secretariat should be brought back under the Council and should operate as such. While the Secretariat provides administrative support to the NASPCP, it must bear in mind that the Council is its ultimate governing body. The working Committees should be aligned with the strategic objectives. The strategic objectives should be operationalized & new projects developed with an explicit contribution to HIV control among MSM and IDUs. A greater control of the Council through the ExeCom should be allowed over resources accessing & mobilization, in partnership with development partners; the role of the Secretariat Director as chief executive officer reporting to the ExeCom & Council should be strengthened. The Secretariat Director should have direct control of over support/staff functions, such as Strategic Information and Capacity Development. Lines of accountability between Council members and the Council must be established more clearly in the implementation of both agency-specific and working committee-designed contribution to the implementation of the AMTP5.

Shift in the appreciation of LGUs from being partners to being co-drivers along with the Council at the local level. Partnership, Networking & Advocacy Committee must be converted to a Localization & Convergence Committee to underscore the primacy of the role of LGUs and community-based CSOs, not just as partners but as co-drivers in the implementation of the national response. As a working committee with a line function, it shall be composed of representatives of LGUs and convened by DILG, shall develop an operational plan specifically designed for LGUs from Categories A&B and shall take full responsibility for LGU/CBO participation in the roll-out of the AMTP5 for the next 3 years.

Moreover, membership in the PNAC should be rationalized on the basis of the following criteria: (1) with existing programs, services and activities that directly contribute to the achievement of the AMTP5; (2) with core mandates that can directly contribute to the performance of the core functions of the Council (oversight, direction-setting and policy making); and (3) with existing constituencies that are targeted by the AMTP5 activities.

Constructive engagement between government and civil society organizations, both at the national level (national government agencies) and the local level (local government units) must be the fundamental and overriding premise in addressing issues and concerns arising in the formulation and monitoring of the implementation of the national response, including its localization.

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1.3 Strengthening PNAC secretariat Staff complement should be augmented to more adequately & effectively perform its tasks and functions, more in competencies than numbers. Core functions of the Secretariat should be limited to capacity development, and strategic communications and information, including monitoring & evaluation of the plan and managing information generated. The responsive and the proactive functions should be clearly delineated. Coordination with LACs should be improved. LACs can be made integral to the TWC working on strategic objective #5, thus mechanisms for cooperation & coordination are instilled.

V.2 Interagency coordination and collaboration strengthened to monitor contributions in the implementation of the AMTP5.

2.1 The National Monitoring and Evaluation System Enhance the existing M&E system with a clear monitoring plan anchored on the results framework and statement of strategic objectives of the national response, with clear baselines, targets and performance indicators, methodologies for generating the necessary information, frequency and the responsible agency for the data collection. Revisit the overall M&E system and monitoring plan vis-Ă -vis the operational plans that shall be developed by the Working Committees and the Secretariat. LGUs and LACs must be supported, coordinated, monitored and strengthened.

VI. Strengthening Capacities of Local Governments and Communities VI. 1. Strengthening Local Governments for Responses 1. 1 Regional AIDS Assistance Teams (RAATs) RAATs should refocus what they are doing to be effective in the response. Since they are strong in advocacy, they can be developed into champions to support LGU planning and budgeting processes as well as to advocate to LGUs to implement priority HIV programs.

1.2. Local HIV/AIDS Council PNAC should establish a system for monitoring the LACS to guide TA strengthening efforts.

LACS need to be strengthened and given exposure to innovative prevention efforts to develop more effective programs. Some LACS are very effective and PNAC should facilitate sharing and cross training through technical exchanges or inter-LGU sharing, where LGUs with more experience can mentor the others.

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1.3. LGU Ownership of HIV Response PNAC and DOH should strengthen LGU capacity to develop City Investment Plans for AIDS and to identify financing sources for HIV. Investment planning for HIV should be expanded in all priority areas A and B, to increase the sustainability of LGUs implemented programs.

VI. 2. Strengthening Communities for HIV and AIDS Responses 2.1. Partnerships - Civil Society Organizations (CSOs)/Communities At-Risk Strengthened Civil society organizations that are on the PNAC should have closer collaborations with LACs. The PNAC Secretariat should organize Partnership Forums between these CSO networks and LACs to explore improved ways of working together.

It is critical that the PNAC should evaluate LGU partnerships with the civil society groups to identify partnerships models for possible replication.

More MSM and PWID community organizations should be engaged and strengthened to be able to increase coverage of the 2 populations at risk, demand for services and policy reform.

Planning for sustainability of LGU/CSO partnerships should be supported. PNAC should engage local stakeholders in sustainability planning.

2.2 Enhancing Network of the National HIV and AIDS Response Evaluation should be conducted to ascertain coverage and effectiveness of the AIDS policy in the workplace interventions, especially in companies and networks with wide labor force.

In line with the above proposed Partnership Forums between CSO networks and the LACs, priority should be the MSM Partnership Forum to develop and implement a strategy aimed at increasing coverage of MSM interventions. .

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Organization and Conduct of the External review of the AMTP5 1. Introduction and objectives of the Review In July 2013, The Department of Health requested the World Health Organization to take steps towards organizing an external Evaluation of the Health Sector’s Response to HIV in the Philippines in October 2013. The evaluation would encompass HIV-related public health issues, including sexually-transmitted diseases and tuberculosis. The evaluation would be conducted simultaneously with a broader review of the multisectoral response to HIV by another team of consultants under the auspices of the Philippines National AIDS Council (PNAC) and UNAIDS. The aim of this combined evaluation was to assess progress achieved and constraints encountered at mid-term of the implementation of the 5th AIDS Medium Term Programme on HIV/AIDS in the Philippines (AMTP 52) covering the period 2011-2016-. The goal of the AMTP5 is to prevent the further spread of HIV infection and reduce the impact of AIDS on individuals, families and communities. This AMTP is structured around 5 Strategic Objectives (Figure 1), two of which were directly relevant to and managed by the health sector, namely: (1) Prevention and (2) Care and treatment. The three other objectives (3-5) would be reviewed by the second team.

Five work-streams for the evaluation framework of the review

SO=Strategic objective

The aim of the combined evaluation was to assess progress achieved and constraints encountered at mid-term of the implementation of the AMTP5.

Philippines National AIDS Council. The 5th AIDS medium term plan: 2011-2016 Philippine Strategic Plan on HIV and AIDS. PNAC, 2011.

2

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2. Two evaluation teams, one goal, one report Through discussions between the agencies sponsoring the evaluation (PNAC, DoH, WHO and UNAIDS) and the chairs of each of the two evaluation teams prior to the launching of the evaluation, agreement was reached that the evaluation performed by the two teams (referred to as Team A and Team B) would complement one another. Team A would evaluate progress against Strategic Objectives 3, 4 and 5. Team B would focus its evaluation on the Health Sector Responses to HIV and related diseases, with a strong focus on Key Populations, covering Strategic Objectives 1 and 2. The table below displays the assignment of roles to each team. In order to ensure minimum duplication of work and leave no gaps within the scope of evaluation, an Inception Note developed by Team A and amended by Team B described the overall evaluation objectives, methods and expected outcome, to the satisfaction of both parties and of entities directly engaged in this evaluation, namely PNAC, the DOH-National Center for Disease Prevention and Control (NCDPC), WHO and UNAIDS.

3. Evaluating a common strategic plan The Strategic Plan for the response to HIV by the health sector was integral to the 5 th AIDS Medium Term Plan. While most of the health sector’s responsibility was mostly enshrined in Strategic Objectives 1 and 2, its work expanded to other Strategic Objectives as well. Cross thematic issues included funding, human rights, primary focus on most at risk populations, strategic information. Thus, the tasks assigned to the evaluation teams A and B had to be further delineated in several informal meetings between the two team chairs and with the lead agencies overseeing the evaluation. Following the process described in details in the Inception report, Teams A and B begun their evaluation work with the refinement of methods and tools and promptly undertook document reviews, key informants interviews, focus groups discussions and site observations according to a pre-set schedule. In addition, Team A conducted an e-survey of stakeholders on their opinion about AMTP5 and PNAC (Annex 2). The composition of Teams A and B appears in Annex 1.

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4. Process Team A was divided into 3 smaller teams, each assigned one Strategic objective. This enabled Team A to include 5 regions, 12 cities including 7 LGUs (Local Government Units) sites in its evaluation. In these cities, team members met and interviewed a wide variety of local authorities and informants, such as Mayors, Municipal Health Officers, LACs, Regional AATs, Social Hygiene Clinics, Community-based organizations. Members of the team also interviewed Female sex workers (FSW) and Men having sex with men (MSM), Persons living with HIV (PLHIV), either individually or during Focus Group Discussions. Hot spots were also visited and sex workers interviewed with the assistance of community members and heads of SHC. The list of key informants is found as Annex 5. The collection of information spanned across a period of 12 days, from October 9 to October 21. It was followed by a four-day period during which the team had the opportunity to pool their information, discuss findings and formulate agreed key recommendations. The first draft of 5th AMTP Assessment and its recommendations were presented early December 2013 by a member of Team A (Marie Labajo) to the PNAC Council. Members requested additional and more detailed recommendations on PNAC core functions and the organizational set-up (including memberships and PNAC secretariat structure). To further discuss and exchange on the proposed recommendations in the PNAC organizational structure, the terms of reference for all bodies (Technical Support Committees, Working Groups, Task Forces, Secretariat) and the rationalization for the membership in the Council, a consultative workshop was conducted 16-17 January 2014 with representatives of 9 PNAC member organizations and agencies (LPP, LCP, DOLE, ACHIEVE, PPA, TLF, DepEd, NEDA, DFA). The main conclusions of this workshop were incorporated by Marie Labajo in the section on the Strategic Objective 4 of the final evaluation report. We would like also to acknowledge the great collaboration of PNACs board members and of many stakeholders who have contributed to inform this review.

Given the wide scope of the evaluation assigned to Team B, it divided into smaller teams, each assigned specific tasks. This enabled Team B to include about 40 local sites/institutions in its evaluation (14 sites in the National Capital Region, 7 in Iloilo, 11 in Cebu and 5 in Davao). In each of these settings, team members met and visited a wide variety of local authorities Mayors, Municipal Health Officers, Social Hygiene Clinics, public and private hospitals, health centres, Maternal and Child Health centres, epidemiological surveillance offices, laboratories, community-based organizations, community-based organizations, prisons and rehabilitation centres. Members of the team also interviewed members of Key Populations during site visits, either individually or in the form of Focus Group Discussions.

The collection of information spanned across a period of about 10 days. It was followed by a three-day period during which the team had the opportunity to pool their information, formulate consensually agreed key recommendations, and flesh-out their report around a commonly agreed table of contents.

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Preliminary results and key recommendations of both teams were presented to PNAC and DOH members on October 29.

5. Report production: Teams A and B contributed to the present report intended primarily for PNAC, Team B also produced a more detailed report focused on the health sector’s response to HIV and STI, with a focus on Key Populations. This report was specifically intended for the Department of Health and public health managers and practitioners in the public, private and non-governmental sectors. Additionally, in response to a late request by the Department of Health to WHO, a short report on the financing of the health sector’s response to HIV is being submitted directly to the Department of Health. These two reports have been only partly incorporated in the present overall report so as to avoid an unnecessary information overload. However, they can be obtained on request from the National AIDS and STI Prevention and Control Programme of the Department of Health.

I.

Epidemiology of HIV: the growing burden

1. Increased number of new HIV diagnosed cases The Philippine HIV and AIDS Registry3 shows that the number of diagnosed HIV cases is rapidly increasing. From one new case every three days in year 2000, to one new case every two hours by the end of 2013. From 1984 to April 2013, there were 13,179 HIV cases reported to the Philippine HIV and AIDS Registry. Ninety-five percent of the 3,154 cases in 2013 were male. The median age was 28 years. The 20-29 year old age group had the most (58%) number of cases for 2013. Of the total, 94% were asymptomatic. As HIV prevention program expands, HIV testing occurs earlier in the course of the infection than a few years back when more than 10% of HIV cases where symptomatic.

These numbers only reflect those who had been tested for HIV and reported. Such increases in the number may be the result of greater and/or more targeted HIV counselling and testing (HCT). In 2009, the IHBSS4 utilized the BED assay –an immunologic responsebased assay- on a small sample of new diagnosed cases (belonging to all most at risk populations) to determine when the HIV infection was contracted. The test showed that about half of the sample was new infections contracted within the last five months.

In terms of geographical distribution of newly diagnosed cases, more than half of all the reported cases came from the National Capital Region (NCR).

However, surveillance results and modelling show that the estimated total number of people living with HIV doubled between 2008 and 2011, and will double again between 2011 Philippines HIV/AIDS Registry, National Epidemiology Center-DOH. 2013 Philippines Integrated HIV Behavioral & Serological Surveillance reports, NEC-DOH, 2007,2009, 2011 3 4

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and 2015. A significant number of people who are infected with HIV still do not access HCT, do not know their HIV status, have no access to treatment services, and are not reported to the Registry.

The HIV national inventory of newly diagnosed HIV cases clearly show the continuous spectacular increase since 2007 of the proportion of cases due to male-to male sexual transmission over the proportion of heterosexual transmission. Data for 2013 –until August- confirm the same increased trend.

Source: ref 2

2. Increased HIV prevalence among MSM and PWID In 2011, while the national HIV prevalence remains below one percent of the adult population and a decrease in HIV prevalence among registered female sex workers was noted, significant increase in prevalence was observed in MSM and in PWID. The aggregated data are coming from the IHBSS conducted in 18 sentinel sites in 2007, 2009 and 2011. The target of less than 1 percent HIV prevalence was achieved among registered female sex workers (RFSW), as well as among freelance female sex workers (FFSW) despite a slight increase among the latter between the baseline of 2007 and 2011. In 2013, new data is available for MSM (in 10 sites) and IDU (four sites). The data shows that the HIV prevalence among MSM has increased more than 7 times since 2007 to reach 3.5% in 2013.

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The 3.5 % HIV prevalence among MSM in 10 sites should not mask rapid spread, as shown in 6 important cities, with HIV prevalence levels broadly between 5 and 8%, showing no signs of slowing down, despite program activities HIV Prevalence among MSM (6 sites) 2009-2013

Among male PWID/IDUs, in 2013, there are signs of stabilization at a very high HIV prevalence level in Cebu at about 52-53% and at 30% among female IDU, a high increase in Mandaue, to reach 42%; and no detectable HIV epidemic in the other 2 sites.

Recent projections estimated the number of PLHIV to be more than 35,000 by 2015, a triple of the number estimated in 2010. This has obviously many implications for the national response and calls for a better articulation of the current institutional arrangements and funding priorities of the response. Based on the National Estimates of Persons Living with HIV, using the 2012 EPP Spectrum5, HIV prevalence will remain below one percent by 2015, at 0.06 percent.

5

EPP/Spectrum, UNAIDS Software, 2012

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3. HIV prevention among MARPs: coverage remains an issue HIV prevention interventions in the country primarily focus on targeted education and risk-reduction counselling delivered through trained peers in high-risk cities. The target populations include female sex workers (FSWs), males who have sex with males (MSMs), persons who inject drugs (PWIDs), and other social hygiene clinic (SHC) clients for sexually transmitted infections (STIs)6. Medicines for the treatment of sexually-transmitted infections as well as preventive commodities (condoms) were distributed to key populations at risk while counselling and testing were performed in social hygiene clinics (SHCs) and other health facilities. Prevention activities for general population were mainly institution-based (provided through the educational system or the workplace) or through social media and consisted mainly of increasing awareness and knowledge, and referral.

Despite an impressive increase in coverage, particularly among FSW and MSW, the program coverage of MSM and PWID has stayed low and has not reached a threshold (estimated at 60%) where programs can make a difference.

Source: IHBSS 2007, 2009, 2011; * MSM 23%, MSW 79%

There were huge variations in coverage among cities. For example, for MSM, except for 3 cities, all others had less than 50% of MSM receiving free condoms in the last year.

Looking at outcome achievements from 2007 to 2011, among RFSW condom use with every client in the last month had not increased after 2009. Among FLSW, there was a slight increase in condom use after 2009. The percentage of MSM who reported use of condom the last time they had anal sex has stayed stable at about 35%, with half of MSM in 2011 saying that condoms were not available. The percentage of PWID who have used condom with sex workers has improved after 2009, especially in Cebu.

6

2011 Philippine MARP and PLHIV Estimates, Philippines National AIDS council, 2012

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Indicators: FSW, condom use with every client in last month; MSM, condom used last time anal sex; PWID, condom use with sex workers. Source: ref3

Progress in promoting safer behaviors among FSW has been slow. Additional efforts are needed, especially to reach free-lance FSW. Among PWID (four sentinel sites/cities), there was an increase in safe injection from 2007 to 2009, associated with the program of Harm Reduction (HR), including provision of sterile equipment to PWID. These efforts resulted in 85% of PWID reporting the use of clean needle source at last injection in 2009; but in 2011 they were only 45% of PWID reporting such a protective behavior, back to similar levels reached in 2007 when the HR program started to scale up.

The new HIV epidemic among PWID in Cebu was not only related to the very limited scale of the harm reduction program because drug use was strictly treated as a criminal offense rather than a social or health issue; it was also related to changes in the price of shabu, a slang term for the drug methamphetamine, that led to an increase in injecting drug use and in the number of injecting drug users, according to key informants. There was indeed a shift to injecting nubain, an opioid analgesic 30 times less expensive per injecting dose, following a huge increase in the price of shabu. The routine practice of sharing the injecting equipment also led to increased HIV infections. But after 2009, the harm reduction program and peer educators could not scale up the required number of needles-syringes to the IDUs at the field level. The percentage of male IDUs (aged more than 24 years old), who received free needles and syringes in the last year, shows a dramatic decline since 2005 when it was 39% to the level of 13% in 2011.

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Trends in behavior and program coverage (%) among PWID

Source: ref3; Condom use during commercial sex

In all SHC, the “minimum� package of education provided to MSM during the streetbased outreach was limited to only few words about STI and HIV transmission and referral to SHC for testing, with delivery of 2-3 condoms, and a pamphlet with basic information.

Most MSMs reached were provided information in a few minutes and in an environment not conducive to being educated. This one-off provision of BCC did not seem to lead to risk reduction behaviour among MSM, including increased condom use. There was no systematic attempt to build relationships and create networks. Condoms distributed were generally not enough. There were not enough promotion and distribution of lubricants, likely due to lack of supplies. Condom/lubricants provided did not fit the quality needs of MSM7. In 2013, lack of lubricants was reported at some sites and some PEs distributed free condoms without lubricants to their groups.

Program coverage specifically for HIV prevention remains low. Based on the results of the 2011 IHBSS, only 23 percent of MSMs were reached with prevention interventions.

Further, only 36 percent of MSMs reported condom use and only five percent have received an HIV test in the past 12 months and know their result. Coverage indicators for PWIDs were also low. Only 15 percent of PWIDs reported condom use during their last sexual intercourse, while only 24 percent of PWIDs reported using sterile injecting equipment. About 63 percent of female sex workers were reached with HIV prevention interventions.

As also mentioned by many respondents and previous evaluations, the lack of leadership and political engagement for HIV was also related to the climate of religious conservatism which prohibited condom use and open education on issues such as sexual orientation and sexual and reproductive health8. The policy environment was deemed a major impediment to the implementation of the program.

Review of Global Fund Round 6 for HIV, 2012 Mid-term review report of 4th AIDS medium term plan, 2005-10, Oct 2008; UNGASS progress report, 2010, 2008, 2006, Philippines, 7 8

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Recommendations 3.1: In order to improve service coverage among Most at risk populations (MARPs), there is a need to intensify outreach services and community mobilization. There is also a need to re-orient service provision and ensure that it is accessible and acceptable to youth and MSMs. Targeting needs to be focused on areas where most HIV infections are coming from both geographically (National Capital Region, Metro Cebu, and Davao) and in terms of key affected populations (MSMs and PWID). Advocacy activities geared towards increasing investments of local government units need to be scaled-up especially in terms of funding provision for HIV prevention activities (behavioural change communication, diagnostic/medical/commodity supplies), human resource augmentation (medical technologists, counsellors, peer educators), and health facility enhancement. There is also a need for continuous engagement of community-based organizations to ensure wider coverage of programs as well as collaboration with the private sector with regard to HIV counselling and testing strategy. A policy on HIV prevention, including condom promotion and harm reduction programme, including needle exchange, should be a priority for PNAC and DOH.

II.

Strategic information

II. 1 Mapping and Counting Key Populations Attempts have been made through a variety of studies, using different assessment methods, to estimate the size of Key Populations and define their risk-behaviors and their factors of vulnerability to acquiring HIV infection or accessing care and treatment. These studies, of which the Integrated, bi-annual HIV Behavior and Serologic Surveys (IHBSS) should constitute a central piece, have shown that the HIV epidemics in the Philippines is highly concentrated in Key Populations, in particular among People who inject drugs (PWID) and Men having Sex with Men (MSM). Accordingly, this report strongly underscores the need to consider these populations as the utmost priority in the targeting of beneficiary population. Risk assessment, the monitoring and evaluation of behavioural trends and outcome and impact measurement should provide the evidence needed to inform the design and implementation of HIV prevention, care and treatment and the allocation of resource.

1.1. Risk assessment The Philippines has developed a robust HIV/STI surveillance system that incorporates many of the components recommended by WHO/UNAIDS for concentrated HIV epidemics (Figure 1.1.). The cornerstone of this system, as in any concentrated epidemic, are biological and behavioural surveys in most-at-risk populations: the Philippine Integrated HIV Behavioral and Serologic Surveillance (IHBSS) in MSM, FSW (registered and freelance) and PWID are frequent (every 2 years), include testing of other STIs, and sampling and recruitment methods that are appropriate for hard-to-reach, stigmatized populations, including time-location sampling for MSM and FSW and respondent-driven sampling for

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PWID.9 The IHBSS was initiated in 2005, following the integration of existing biological surveillance (since 1993) and behavioural surveillance surveys (since 1997). Initially, 10 cities were included for FSW and MSM and 3 cities for PWID, with additional sites added over time to meet Global Fund reporting requirements. The invaluable trend data produced by the IHBSS have proved instrumental in allowing the timely detection of the recent and rapid increases in HIV prevalence among PWID, MSM and freelance FSW beginning in 2007.

A formative stage preceding each round of the IHBSS includes mapping and enumeration of MSM and FSW to support size estimation and the targeting of local prevention activities. The 2013 IHBSS surveillance round added transgender women as a new population (in Cebu), following a recent global review of evidence of high HIV burden in this group globally.10 National HIV and STI case reporting systems (for etiological diagnosis of syphilis, hepatitis B, hepatitis C and gonorrhoea) are also in place with high coverage of health facilities. In 2012, coverage of the Sentinel STI Etiological Surveillance System (SSESS) included 83% of public and private facilities reporting, exclusive of the DOH social hygiene clinics.11 Both the HIV and STI reporting systems capture data that allow disaggregation by age, sex and the most-at-risk groups tracked by the IHBSS. In addition, the HIV and AIDS Registry captures initial CD4 and symptomatic vs. asymptomatic cases to allow for disaggregation of cases diagnosed as advanced HIV infection.

Tracking of HIV deaths began only recently in January, 2013, with the introduction of national mandatory reporting of HIV deaths, so that there is currently very limited information on HIV mortality.

Surveillance of resistance of HIV virus to antiretroviral medications in treatment na誰ve individuals was reportedly conducted in 2010, with plans for a second round in 20142015 including genotyping, however, no documentation of these efforts could be identified for this review.12 Similarly, drug resistance testing among HIV positive participants of the IHBSS has reportedly been conducted, but is not mentioned in either the study protocol or available findings documents.13 The National Epidemiology Center (NEC) of the DOH manages all of the above surveillance activities. In addition, NEC develops estimates and projections of the number of people living with HIV and the impact of HIV biennially using UNAIDS EPP and Spectrum models, and more recently, the Asian Epidemic Model. NEC has also carried out prioritization exercises drawing on IHBSS data and size estimates, leading to classification of cities as

9

National Epidemiology Center (2011). Protocol for the Philippine Integrated HIV Behavioral and Serologic Surveillance (Philippine IHBSS 2011).

10 Baral, S D, T Poteat, et al. (2013). "Worldwide burden of HIV in transgender women: a systematic review and metaanalysis." Lancet Infect Dis 13: 214-222.

11 The coverage figure is based on analysis of the SSESS database conducted as a part of this review.

12 Personal communication with Genesis Samonte, director of the HIV team of the National Epidemiology Center, on 31 October 2013.

13 Ibid.

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Category A (highest priority for HIV interventions), B and C, and others (not prioritized). The prioritization is widely used as a basis for geographic targeting of HIV activities.

Although the review identified important gaps in the kinds of data produced by surveillance in the Philippines (noted below) the most pressing issue relates to analysis, dissemination and use of existing data. Key achievements, limitations and recommendations regarding risk assessment follow.

Figure 1.1. HIV Surveillance components, Philippines Surveillance component Integrated HIV behavioural and serological surveillance (IHBSS)

Methods

Geographic coverage of data

Frequency

HIV and STI testing Face-to-face behavioural questionnaire

MSM

Time-location sampling

FSW (registered and freelance)

Time-location sampling

PWID

Respondent-driven sampling

Angeles, Baguio, Cagayan de Oro, Cebu, Davao, Gen Santos, Iloilo, Zamboanga, Mandaue, Bacolod, Pasay, Quezon City, Makati, Marikina, Pasig, Mandaluyong, Manila, Caloocan Angeles, Baguio, Cagayan de Oro, Cebu, Davao, Gen Santos, Iloilo, Zamboanga, Mandaue, Bacolod, Caloocan, Makati, Mandaluyong, Manila, Marikina, Pasig, Pasay, Quezon Cebu, Gen Santos, Zamboanga, Mandaue

Transgender women

NA

Cebu

Initiated in 2013

IHBSS locations (18 cities) National

Every two years

IHBSS locations (18 cities) Social Hygiene clinics (89 locations)

Every two years

Cebu National

One off

Every 2 years

Every 2 years

Every 2 years

Population size estimates

MSM

FSW (Registered and Freelance)

PWID

Mapping and enumeration from IHBSS* General population survey Mapping and enumeration from IHBSS Social Hygiene Clinic client rosters Unique object multiplier in Cebu General population

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HIV case reporting

STI case reporting

survey Routine reporting of newly diagnosed cases of HIV infections Routine reporting of STI (etiological) for syphilis, hepatitis B, hepatitis C, and gonorrhoea **

Antenatal None surveillance Mortality Routine reporting of HIV surveillance deaths HIV incidence None surveillance Notes:* These sources are not mentioned in the most

Public and private facilities nationally that conduct HIV testing

Ongoing

Public and private facilities nationally that provide STI diagnostic services

Ongoing

-

-

All physicians

Ongoing

-

-

recent published estimates, 14 or documented in IHBSS factsheets, however NEC indicated that these data have been collected. ** Gonorrhoea is assessed routinely and in IHBSS surveys by gram stain. In 2012-2013, a “special surveillance� round was undertaken to estimate the prevalence of gonorrhoea and Chlamydia by PCR and to determine the genotype of gonorrhoea in selected cities.

1.2. Limited analysis and access to IHBSS Analysis and dissemination of data and the technical details of IHBSS have been sorely lacking. Although scientific manuscripts based on these data have appeared in peer-review journals, the review team found great frustration among health facilities and stakeholders at national and local levels regarding access to technical reports and findings. Findings from the IHBSS are not published on the NEC website as in the case of reports from the AIDS Registry and no complete technical report has been released since 2005, with the exception of a 2007 report for the MSM group only. Findings are displayed annually at a national workshop, but only in presentation format. There has been a laudable effort to disseminate abbreviated factsheets from the 2009 and 2011 rounds to local governments and health facilities, however these are not available online and do not provide adequate detail of the samples obtained, uncertainty intervals around the estimates, or study methods, all of which are necessary to interpret the important recent trends in prevalence. For example, interviews with NEC staff found that changes in study inclusion criteria have changed over time, yet these are not documented. Although the study protocol describes methods, technical reports are needed following each surveillance round in order to describe actual implementation (which may vary in practice) and develop a more complete analysis of behavioural question items, most of which are not presented in the factsheets. In addition, researchers at universities attempting to access IHBSS data for purposes of graduate and postgraduate research have been routinely rejected, resulting in further sub-utilisation of this invaluable data source. The lack of disclosure of survey findings and methods is surprising, considering that these surveys are publicly funded and, as is the practice in most scientifically advanced Philippine National AIDS Council (2011). 2011 Philippine Estimates of the Most At-Risk Populations and People Living with HIV 14

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countries around the world, findings, methods and data bases should fall in the public domain even before their publication in professional journals. The survey results analysis would benefit from expertise in data analysis and presentation. As there is concern by NEC regarding human resources capacity to develop technical reports, an expert panel (rather than or in addition to the existing technical advisory group concerned with the implementation of the surveys, should be set up to review and provide scientific guidance on and input to drafts. The existing Technical Advisory group established to oversee the surveys does not seem to be in a position to perform these tasks. An expert panel consisting of members with extensive epidemiological, behavioural, social and statistical expertise should be engaged in data analysis and presentation. The costs involved in marshalling the needed expertise should be carved out of the budget set aside for the biannual IHBSS. Recommendation 1.2: The NEC should make widely available complete technical reports from IHBSS surveillance rounds accompanied by actionable factsheets within 6-12 months after the completion of each surveillance round, through online publication, local briefings and distribution of hard copies. A thorough description of the methods applied, samples obtained, analytic techniques, and confidence intervals should be included in all materials. The current IHBSS Technical Working Group has not provided effective oversight regarding dissemination to date. Thus, scientific oversight should be carried out by the leadership of the NEC (NCDPC) and/or the Office of the Secretary of Health (which oversees NEC), jointly with an expert panel, feeding early results onto the Department of Health, Local Governments and the PNAC Executive Committee, given the importance of IHBSS data to HIV programming.

1.3. Local government resistance to data sharing IHBSS findings, including factsheets, are not published online. One reason cited by NEC is that local government officials sometimes demand that findings for their area not be made public, due to concern about the political implications due to, for example, findings of high prevalence. In some instances, local governments have threatened to withdraw their participation in future IHBSS if NEC makes findings public.

Recommendation I.3: Ahead of IHBSS surveillance rounds, NEC should enter into a formal agreement (e.g., via an MOU) with local governments selected to participate, stating that national and local findings will be made publicly available through technical reports, factsheets and other media, and made available online, regardless of what the results show. Civil society should be made a part of this process via national and local AIDS councils so that their voices may be heard.

I.4. Coverage of IHBSS surveillance among people who inject drugs Most major urban cities and regions—most notably NCR—are not included in surveillance of PWID, so that the coverage of surveillance appears limited. Injection drug use behaviour could potentially be present in many parts of the country and could theoretically spread from Cebu elsewhere. Yet, the review found no evidence suggesting that the presence of IDU had been systematically explored in large urban areas throughout the country. Rapid

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Assessments of Vulnerability (RAV) to improve local understanding of risk behaviors were carried out in 2010 and 2012 in larger cities; however the framework offers limited guidance to local governments regarding how to assess the presence of PWID. Furthermore, there are no criteria for establishing new IHBSS sites based on RAV findings: thus surveillance does not seem equipped to adapt quickly to changes in injection drug use patterns nationally.

Recommendation 1.4: Building on the RAV, regular assessments to identify the presence of significant PWID populations should be conducted in urban areas that meet objective criteria (such as all Category A sites) nationally. Additional criteria should be established to determine under what circumstances findings from these PWID vulnerability assessments should lead to establishing a new IHBSS site for PWID. The NEC’s guidelines on rapid assessment of vulnerability should be enhanced to ensure that the assessments systematically gather and triangulate data from hospital emergency departments, substance abuse rehabilitation centers, police and local NGOs working with drug users in order to identify evidence of injection drug use.

1.5. Reaching the highest risk individuals through local mapping Social hygiene clinics and others involved in outreach and prevention for most-at-risk populations would benefit greatly from information about the locations where high-risk behaviors among members of most-at-risk populations are common. Mapping is currently done as part of the IHBSS to identify where members of most-at-risk populations can be found, and how many are at each location, however mapping does not currently help peer educators identify where to find the highest risk individuals within these groups: those with the highest number of partners, lowest condom use, most needle sharing, or overlapping risk behaviors such as MSM or FSW who inject drugs. Such information at the local level could improve the efficiency and effectiveness of outreach and prevention to reduce HIV transmission.

Recommendation 1.5: To guide more effective targeting of prevention, data from IHBSS should be used to generate local maps that identify those locations (establishments and street locations) with the highest concentration of highest-risk behaviors, including patterns of low condom use, high number of partners and frequent needle sharing, and overlapping risk (MSM-PWID, FSW-PWID).

Organizations carrying out outreach, including social hygiene clinics and needlesyringe programs, should be trained on how to use this information to target individuals at highest risk for HIV infection and transmission.

1.6 Monitoring HIV among pregnant women in areas with heavy HIV burden As levels of HIV among MSM, PWID and FSW increase, transmission may begin to move beyond these groups. A main goal of surveillance is to detect such emerging trends so that prevention activities can respond quickly. WHO/UNAIDS recommendations for surveillance in concentrated epidemics recommend surveillance of HIV infection among antenatal women in areas with significant epidemics among most-at-risk populations, in order to allow for

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early detection of rising levels of HIV In the general population. This can be done two ways: (1) through routine HIV screening, provided the coverage of testing is high enough to eliminate concerns of selection bias due to refusals to test; or (2) periodic antenatal surveillance surveys. In the Philippines, levels of HIV screening in antenatal settings are too low to permit useful tracking of prevalence. Reportedly, efforts to study antenatal settings have been carried out in 2009 in Davao and more recently in Cebu, however findings were not available and there is no plan to continue these efforts systematically.15 Recommendation 1.6: Estimates of levels of HIV infection in antenatal women in cities where high levels of HIV infection (e.g., at least 10%) have been detected in most-at-risk populations should be incorporated into local and national surveillance systems by either (1) strengthening routine screening among pregnant women in these areas to bring HIV testing coverage to at least 90%; or (2) conducting periodic antenatal surveillance studies at selected sites in these areas every 1-2 years.

1.7 Surveillance in closed settings Prisons worldwide are often home to the risk behaviours most central to the Philippines’ HIV epidemic: MSM and injection drug use. Yet, while some screening for HIV has occurred in jails as a result of local initiatives, and some social hygiene clinics have established support to local jails to ensure treatment is available to inmates identified with HIV (such as in Cebu City), there has been no systematic assessment of these risk behaviours and HIV prevalence in prisons in the country. This is needed most in areas with outstanding epidemics— Category A areas—to determine the need for and scale of HIV and STI prevention in prisons.

Recommendations appear elsewhere in this report for scaling-up HIV and TB prevention, care and treatment in prisons.

Recommendation 1.7: Formative research to characterize MSM and injection drug use risk behaviours in prison populations should be carried out to determine the need for biological and/or behavioural surveillance. Criteria for selecting sites for the formative assessment should be established and should include consideration of (1) number of inmates; (2) geographic proximity to Category A areas. These data should be used to design, implement and monitor HIV and TB prevention, care and treatment in prisons.

1.8 Population size estimates for MSM, FSW (freelance and registered) and PWID have been developed by the NEC, drawing on several data sources, including client rosters from social hygiene clinics and mapping and enumeration carried out during the IHBSS for MSM and FSW. Rates of injection and male-to-male sexual behaviours from national general population surveys have also been used. A multiplier estimate—by comparing data on the reach of a local service or activity with IHBSS survey data—was used in the 2013 IHBSS round to estimate the number of PWID in Cebu. However, previous use of multipliers in 2009 and 2011 is not documented. Although size estimates appear on IHBSS factsheets, the review Personal communication with Genesis Samonte, director of the HIV team of the National Epidemiology Center, on 31 October 2013 15

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found that some social hygiene clinics and other local stakeholders are not familiar with size estimates for their service areas.

Recommendation 1.8a: Dissemination of population size estimates for most-at-risk populations in Category A (and potentially Category B) areas should be improved by (1) documenting the specific methods employed and findings (including uncertainty ranges of the estimates) from size estimation exercises in technical reports within 6 months of completion; and (2) Providing technical support and capacity building to improve their understanding and use of size estimates in prevention activities.

Recommendation 1.8b: Size estimation using the multiplier method should be integrated into all future IHBSS surveillance rounds for MSM, freelance and registered FSW and PWID, using services and/or unique object multipliers. Given the wide confidence intervals typically associated with these estimates, multiple multipliers should be used for each population as possible. Methods and findings from multiplier estimates should be documented as in the preceding recommendation.

II.2. Assessing outcome and impact: Moving beyond HIV prevalence.

HIV prevalence is a poor measure of how the epidemic is changing over the time, particularly as prevalence rises and as treatment becomes more widely available. This is because prevalence will tend to increase as people on treatment live longer lives (a very positive outcome) and tend to decrease as more people die of HIV (a negative outcome). Thus, tracking prevalence as a measure of success is problematic. Information on mortality and incidence is needed.

2.1 Monitoring and assessing outcome and impact: The national HIV programme is currently not able to provide the evidence of positive response to prevention, care and treatment as could be measured by incidence and prevalence of HIV or morbidity, disability and mortality associated with or caused by HIV. The only objective trends observed in Key Populations are rising prevalence rates in samples of Men having sex with Men and People who inject drugs. Newly available technologies and a broader understanding of impact measurement should be considered when building the evidence of the combined effects of prevention, care and treatment on the spread of HIV as well as its individual and collective impacts. Such measures should combine the assessment of: HIV prevalence trends in Key Populations (Registered and unregistered female and male sex workers, Men having sex with Men and People who inject drugs, Transgender and Transsexual people; Sexually Transmitted Infection patients; TB patients); HIV incidence using newly available assays; mean CD4 count in newly diagnosed People living with HIV; the incidence and prevalence of STIs as proxys for assessing changing preventive and care seeking behaviours. Other measures of outcome and impacts should consider behavioural trends (e.g.; Use of condoms

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and other safer sexual practices; use of sterile needles and other harm reduction practices such as drug substitution and treatment) as well as trends in the ability of Key Populations and People living with HIV to be freed of stigma and discrimination, resume productivity, increase their autonomy and participation in public affairs, and improve their quality of life.

Recommendation 2.1: Three decades into the HIV epidemic, the Philippines HIV programme should not only remain accountable on the delivery of quality services and goods and use of resources but also acquire the capacity to evidence the outcome and impacts of the health sector’s response to HIV. This implies the strengthening of epidemiological surveillance, the application of new laboratory technologies along with greater dispersion of existing technologies (e.g. rapid tests for HIV and STIs, CD4 count, Viral Load), stronger data linkages from individual entry into active prevention programmes, HIV testing and counselling, enrolment in the care and treatment continuum, and eventually through the end of life, as well as improvements in social, behavioural and economic determinants of health and wellbeing.

2.2 HIV incidence: Tracking HIV incidence—the rate of new infections—is critical to understanding how the epidemic is evolving over time. The national M&E plan for AMTP 5 proposes using the number of new cases of HIV reported (from the HIV and AIDS Registry) as a measure of incidence, but this is not a good measure of recent infection because of HIV’s long asymptomatic period and potential variations in patterns of routine reporting. Better measures include laboratory assays for incidence and tracking prevalence trends in young childbearing women.

Recommendation 2.2: The national surveillance system should incorporate measures of HIV incidence, including two strategies. First, incidence assays should be applied to specimens from IHBSS studies to estimate incidence among key populations, potentially pooling samples across nearby cities to obtain sufficient sample size.16 Second, trends in HIV prevalence should be analysed among young childbearing women (ideally younger than 20 years old, in whom infection is most likely to be recent) from antenatal facilities in the geographic areas recommended under Recommendation I.6.

2.3 Mortality: A new HIV mortality report was introduced by NEC in January, 2013, however it is acknowledged that only a small fraction of HIV deaths are likely to be detected and reported by health facilities. Yet, high-quality mortality data are needed for two reasons: (1) Data on all deaths among PLWH (whether attributable to HIV or not) are needed to exclude PLWH who have died from measures of treatment retention; (2) Data on deaths attributable to HIV are needed to track patterns in HIV mortality, which is crucial to improving the effectiveness of care and treatment services. Standard algorithms exist to identify both kinds Reportedly, incidence assays have been applied previously, but there is no evidence of them in the IHBSS study protocol, factsheets or the one technical report available for 2009 in MSM. 16

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of deaths, even in the presence of under-reporting of HIV as a cause of death on death certificates.17 Recommendation 2.3: NEC should develop methods to regularly (every 1-2 years) cross-match the HIV/AIDS registry with the national civil deaths registry in order to capture (1) deaths among people with HIV, due to any cause; and (2) deaths attributable to HIV. Analysis based on these combined data should be developed to improve understanding of patterns in mortality (demographic and risk characteristics, relation to late diagnosis and treatment characteristics) at the national and local levels, with the aim of improving the effectiveness of care and treatment.

2.4 Morbidity due to opportunistic infections: Monthly reports containing analysis of the AIDS registry are informative and disseminated widely through the NEC web site. However, analysis of care and treatment in these reports is limited to presenting the number of patients currently on ART. NEC is now piloting a new data collection form that would capture opportunistic infections at the time of HIV diagnosis. However, there is currently no data available to determine patterns in opportunistic infections after diagnosis—over the course of care and treatment.

Recommendation 2.4: AIDS registry reports should summarize rates and opportunistic infections and characteristics of PLWH who have OIs. Summaries of trends in the rate of opportunistic infections should be made available to treatment hubs with support in using these trends to improve treatment effectiveness.

2.5 Improving analysis presented in STI case reports: Similarly, SSESS quarterly reports contain useful data on the number of STI cases detected, but the utility of these reports could be greatly improved by including trends over time and breakdowns by age, sex and type of facility, in order to understand the occurrence of STI in different populations and across types of service (e.g., blood banks, hospitals and social hygiene clinics). Analysing and facilitating access to these data would also improve the likelihood they are used to improve services.

Recommendation 2.5: Analysis presented in the SSESS reports should be expanded to include breakdowns by age, sex and type of facility. The analysis should be made more accessible and actionable by including figures illustrating trends, characterizing STI risks and vulnerability, and making the reports available to health practitioners and researchers online.

Kowalska, J D, A Mocroft, et al. (2011). A standardized algorithm for determining the underlying cause of death in HIV infection as AIDS or non-AIDS related: results from the EuroSIDA study.HIV Clinical Trials 12, 2: 109-117 17

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II. 3. Monitoring retention and quality across the cascade of health services 3. 1. Bringing those in needs to Treatment The DOH began providing ART in 2004. Enrolment has increased rapidly from 56 patients in 2005 to 1274 in 2012.18 ART eligibility is becoming increasingly more inclusive, moving from a threshold of CD4 count ≤ 200 in 2005 to ≤ 350 in 2012 and will potentially expand to ≤ 500 in response to more recent WHO recommendations, bringing more individuals into treatment. Figure 3.1 shows the services cascade at a national level for 2012, based on cross-sectional data. There were an estimated 22, 840 estimated people living with HIV in 2012 and by the same year cumulatively 11,729 (51%) had been diagnosed with HIV, excluding deaths reported by health facilities. Of these, there is currently no information on the number of PLWH that have been linked to care. However, 4,115 individuals (18% of the estimated PLWH) were enrolled in ART as of May 2013 (the figure is not available closer to 2012 year-end). Finally, based on a cohort analysis conducted as a part of this review, an estimated 78% of individuals enrolled in ART continue in treatment at 12 months. These numbers are suggestive of loss-to-follow-up, which is consistent with perceptions among staff at treatment hubs and social hygiene clinics. Loss-to-follow-up particularly among PWID is seen as an important problem. Yet, there is no systematic monitoring of referrals and retention in care and treatment. Further, social hygiene clinics and treatment hubs do not appear to be using the data they have for quality improvement, with few exceptions.

Figure 3.1 National cascade of HIV care and treatment, and data gaps Estimated PLWH

22840 22840 22 840

Diagnosed with HIV

11729 0

EPP/Spectrum model-based estimates for 2012 At least 1.3 million HIV tests were performed in Philippines in 2012

Cases of HIV infection reported to NEC from 1984 to 2012, excluding reported HIV deaths

National modelling exercise 19

National HIV and AIDS registry 20

18

Ibid.

19

bid.

National Epidemiology Center (2013). Philippine HIV and AIDS Registry, January 2013 report.

20

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Enrolled in care

Enrolled in ART

?

4115

Retained in ART

78%

Enrolment in care and eligibility for ART are not tracked.

None

Individuals reported to NEC as enrolled in ART as of May 2013 at the 17 DOH treatment hubs

ART database 21

Estimated 12-month retention based on enrolment and monthly follow-up forms submitted to NEC for the 306 patients who enrolled from January to March, 2012

ART database

Recommendation 3.1: Standardized mechanisms for referral (see Recommendation on referral) should be accompanied by standardized mechanisms to routinely monitor that referrals have actually resulted in linkage between services (such as program registers and summary reports), using a unique identifier such as the SACCL code. Procedures for tracking referrals should be incorporated into existing SOPs and training and supportive supervision should ensure their use. Data on trends over time in the percentage of referrals that are realized—from outreach to testing, testing to care, and care to treatment—should be made available to social hygiene clinics, treatment hubs and TB treatment centers and DOTs facilities. Procedures for personnel to meet periodically (e.g., quarterly) to review these data and collaboratively identify measures to improve referrals should also be established. A data field for source of referral into testing should be added to the HIV and AIDS registry form in order to capture referrals from TB patients, antenatal care and private testing facilities.

3.2 Monitoring retention of pre-ART patients. Currently there is no mechanism to track linkage from testing to care. Only individuals who enrol in ART are followed. However, recently NEC began piloting a new reporting form for patients in care (“Form B”, an add-on to the HIV and AIDS Registry). Tracking loss-to-follow into care, and retention in care, could be accomplished by requiring regular follow-up reports using Form B or, alternatively, a facility-level register that records visits by patients in care. Such a register implemented in 21

National Epidemiology Center (2012). Philippine HIV and AIDS Registry, December 2012 report.

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Excel, Epi-Info or other software and shared periodically (e.g., monthly) with NEC in a way that preserves patient confidentiality (i.e., without personal identifiers) could prove less burdensome to health facilities and reduce the data entry burden on NEC. Either system— follow-ups using Form B or facility-level registers—would provide the raw data needed to track loss-to-follow-up and retention in care.

Recommendation 3.2: Linkage to and retention in care should be routinely monitored either through routine reporting using the new Form B, or by establishing facility-level registers that capture sufficient data on enrolment and follow-up (including SACCL code) to allow tracking of individuals over time. Additionally, standard care and treatment reports at the facility and national levels should include summaries of patients who are awaiting eligibility screening, those in pre-ART and those in ART. Cohort-based measures of retention in both care and treatment should be developed and procedures established for data review and decision-making to ensure that the data are used regularly (e.g., monthly) for program improvement.

3.3 Tracking the cascade for most-at-risk populations. Given the country’s concentrated epidemic, tracking the cascade for MSM, FSW and PWID is as important as tracking nationallevel figures, particularly given concerns of increased loss-to-follow-up among PWID. Currently, population size estimates provide the data needed to estimate the first stage of the cascade by risk group. The HIV and AIDS Registry also identify each of the most-at-risk populations; because the Registry also records the SACCL code, tracking the cascade for each most-at-risk population is possible.

Recommendation 3.3: At national and facility levels, trends in retention and loss-tofollow-up for MSM, FSW (registered and freelance) and PWID should be routinely monitored through standard reports (ideally the same reports developed under Recommendation III.2 with procedures for regular review and decision-making based on findings. Analysis to generate these trends would be most easily generated at the national level, given that national-level databases would allow the analysis to account for transfers between facilities.

3.4 Monitoring health facilities’ adherence to services protocols. The review team found instances of NGOs and laboratories using non-standard forms for pre- and post-test counselling. Non-standard practices—such as counsellors failing to review test results as a part of post-test counselling—were also observed in multiple social hygiene clinics. During visits to social hygiene clinics and treatment hubs, physicians and counsellors were often unable to produce SOPs for testing, care and treatment. The review found no evidence of routine supervision or monitoring of procedures at these facilities.

Recommendation 3.4: The level of training and supportive supervision to help HIV testing and treatment facilities adhere to services protocols should be strengthened through inception and periodic in-service refresher training activities centred around existing Standard Operating Procedures.

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3.5 Putting it all together: Continuous quality improvement. The review team found that with few exceptions, data and analysis are not available or used at the local level to improve services and support is not provided to build local capacity to use data. Many of the recommendations above involve generating and reviewing indicators of program quality and effectiveness, such as referrals realized, retention and morbidity. Use of these data would be most effective if organized into a single quality improvement report and a single review process carried out at the local level.

Recommendation 3.5: A single report should be developed for use at the LGU level providing data and trends in indicators of program quality and effectiveness, such as referrals into care and treatment, retention in care and treatment, and morbidity. A standard procedure should be developed to ensure regular review (e.g. quarterly) of the quality measures by individual health facilities (social hygiene clinics, treatment hubs, TB facilities) and local HIV collaborative HIV teams in order to facilitate early detection of problems and collaborative solutions. The national level (NEC and PNAC) can support these efforts by providing guidance, training and supportive supervision for the review and interpretation of the quality indicators and problem-solving process.

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3.6 Human resources for strategic information: essential, under-resourced and vulnerable.

The numerous recommendations above are essential: they address gaps needed to ensure that HIV program and services are effective and lead to favourable outcomes and impact.

However, implementing these recommendations will require new investments in human resources and capacity. The HIV Team at NEC has two permanent positions: the director and deputy director. All other staff are on short-term (generally one-year) contracts, creating instability and high likelihood of attrition. The workload of NEC, including all of the elements listed in Figure 1.1, in addition to estimations and projections and prioritization exercises, is extremely heavy. With just one regional surveillance advisor in each of the nation’s 17 regions, there is little regional capacity to provide support for these activities. Currently, 4 NEC staff are involved nearly full-time “validating� data: manually checking for inconsistencies in routine reporting data and IHBSS questionnaires. Notably, a rationalization plan under consideration by the DOH at the time of this review contemplates reductions to human resources and national and regional levels. Ensuring that the minimal components for HIV/STI surveillance and program monitoring are in place will require just the opposite: investment and strengthening of human resources and additional financial resources to attain adequate coverage of all high-priority (Category A) cities. In addition to seeking additional resources, savings can be had by improving efficiency. For example, savings could be attained by automating the data entry of the considerable volume of IHBSS questionnaires, work that is required every 2 years for three populations in 3-10 cities per population, amounting to about 20,000 questionnaires per surveillance round. This results in over-utilization of staff and a long delay (reportedly, 5-6 months for data entry and validation) before statistical analysis of the data can commence.

Recommendation 3.6: The bulk of this work would be better accomplished by computer programs, with manual review reserved for following up on those inconsistencies that are automatically detected. Such validation checks could be automated at low cost.

Optical Character Recognition (OCR) technology should be introduced to automate the data entry process and reduce data entry error. This would require an initial investment, but would appear quite justified given the high volume of work involved.

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III.

Continuum of Prevention, Care and Treatment

III. 1. Prevention packages for Key Populations In the Philippines the HIV epidemic continues to grow and is fast shifting from a low epidemic to a concentrated epidemic among key populations, that include men who have sex with men (MSM), people who inject drugs (PWID) and sex workers (freelance sex workers in particular).22 This chapter will focus on populations that are most at risk for HIV infection. It reviews their current access and use of services and suggests means to rationalize services targeted at them. Minimum packages of services are emphasized for key populations at hat are at greatest risk of becoming infected and/or being denied access to treatment, For other key populations, reference to international standards of best practice will allow the reader to construct minimum packages that would be best adapted to local needs and capacities. This chapter also comments on access to condoms and the diagnosis and treatment of STIs among key populations. A subsequent chapter will examine in some depth current practices and gaps concerning HIV counselling and testing, a pivotal component of the continuum of HIV prevention, care and treatment.

1.1 Policies and Strategies relevant to prevention, care and treatment packages for key populations At national level, there are policies and strategies attached with the comprehensive packages of HIV prevention interventions for PWID, MSM and transgender people, as well as sex workers, which are defined in the fifth national AIDS Midterm Plan 2011-2016 (AMTP5). The AMTP5 provides comprehensive guidance to HIV and STI prevention and control in the country. Over the last three years, progresses were made against the strategic objective on the prevention of HIV and other STIs (SO 1) of the national AMTP5. However, the current prevention responses are patchy and fragmented. The coverage of prevention interventions among key populations (SW, MSM, PWID) remains very low at below 30%.23 Moreover, prevention activities are largely uniform due to the mostly donor-driven and project-based approach they tend to promote. The 2013 evaluation of the Global Fund, Round 6, reported that the numeric targets (example for MSM and sex workers) were reached, but no evidence indicated that any significant impact on the HIV epidemic among these key populations had been achieved. This draws serious concerns on both coverage and quality of prevention efforts.24 The main bottleneck has notably been the gap between the development of the national guidance and its subsequent implementation at local level. To-date, the defined comprehensive package of intervention services for key populations has not been IHBSS 2007-2013, NEC, the Philippines.

IHBss 2013, and AEM 2013, NEC, the Philippines 24 Evaluation report (2013): Global Fund Round 6 HIV Grant 2007-2012 22 23

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implemented systematically anywhere in the country. There are many reasons for the gap between guidance and practice: a) insufficient resources at national level to support implementation of national operational workplans; b) insufficient technical assistance provided to regions or local government units (LGUs), due to limited capacity and resources at central and regional levels; c) lack of a consistently-supportive environment to scale up effective HIV prevention interventions among key populations (PWID, SWs, MSM and transgender people); d) Recent national guidelines have not yet reached all level health service facilities, where reached, the level of understanding of the comprehensive packages for key populations is low; e) HIV is often not a priority of LGUs and HIV prevention is often left behind HIV treatment when limited resource are available; f) Low capacity and weak commitment at LGU level to deliver necessary prevention services for key populations where political will and leadership are lacking; g) STI services do not always reach the most important target groups, and there are serious concerns on the efficiency and effectiveness of present STI services provided by social hygiene clinics. SHC overloaded on inefficient and effective STI smearing, thus failed to respond to the need of HIV prevention.

Peer education remains the main strategy to reach hard to reach key populations, but most provide limited, simple, disease-focused information, with very weak linkages to HIV testing and counselling and other health services. The prevention activities are also largely ignoring the psychological and social contexts in which risk and preventive behaviours take place.

There is a need to strengthen strategic and critical thinking and action; to take a more practical approach to the adoption of evidence-based international programs to Philippines' unique circumstances; and to undertake proper needs and capacity assessments before starting a service or program. In a context where the actual risk of becoming infected with HIV is on the rise and the perceived risk of becoming infected with HIV is still low, awareness information and behaviour change approaches are insufficient, and lack of good linkage with HTC and other necessary services. Situation analyses (by large projects in particular) have been repeatedly done, but ended up with very limited actual implementation of prevention services; Operations research and assessments of the effect of specific prevention activities are lacking.

Recommendation 1.1a: The overarching principle is respect for and protection of human rights, ensuring health services are delivered stigma-free and friendly manner to key populations in health-care settings. Specific efforts should be made to address the bottleneck prohibiting the full implementation of the national guidelines at local level. The comprehensive packages for key populations should be reassessed, a minimal package of prevention interventions should be defined and accompanied with a concrete quality assurance mechanism. With the present level of response, the target of reducing HIV new infections among key populations by 50% by 2015 will unlikely be achieved, and a larger epidemic may spread both within and beyond the MSM population, given the rampant risk factors prevailing in the country.

Recommendation 1.1b: The development of a master health sector plan should be considered, maximizing the utilization of the existing health infrastructure, social hygiene clinics in particular, to mainstream evidence informed and rights based

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prevention services to key populations. In addition, building staff capacity at SHCs to expand its scope of services in order to cover all key populations and establish a stronger partnership with NGOs and CBOs working with key populations. Local innovation of service delivery models should also be encouraged and good practices documented for sharing and replication.

1.2 Prevention packages for Key Populations Effective HIV prevention requires the combination of appropriate interventions targeting populations who are at risk of acquiring or spreading HIV infections. Priority prevention efforts should always follow the epidemic – from where and whom the new infections come from. It is clearly noted that in the Philippines the HIV epidemic continues to grow and is fast shifting from a low epidemic to a concentrated epidemic among key populations, that include men who have sex with men (MSM), people who inject drugs (PWID) and sex workers (freelance sex workers in particular). 25 1.2a People who inject drugs (PWID) HIV infection among PWIDs was first detected in Cebu out of five cities during the 2005 round surveillance, the prevalence remained low at less than 1% until the year 2009, perhaps due, at least in part, to the intensive needle-syringe programme supported by Global Fund round 3. Unfortunately this programme was phased out in 2009. Two years later, in 2011, the prevalence rocketed up to 54% among PWID who were using 'shooting galleries ' where high rate of needle and syringe sharing behaviour prevailed. Since then, Cebu has become a high spot for HIV transmission among PWID. Significant HIV spread among PWIDs has not been documented elsewhere in the country but drug use patterns and impacts are poorly documented in other large cities, including NCRs (Metro Manila in particular).

Harm reduction for HIV prevention among people who inject drugs is limited. Active distribution of clean needles and syringes is limited to only one location: Cebu city where a trial is under-way in one facility at which only 1-2 staff are permitted to provide needles and syringes to PWID. Peer educators hired under a GF-Transitional Funding Mechanism project often provide only health information during outreach while they are not allowed to distribute free needles and syringes. The endorsement by the Dangerous Drugs Board (DDB) of a pilot needle and syringe exchange project in one barangay in Cebu where HIV among PWID reached more than 50% has not yet been implemented.26 Through the needles and syringes exchange project in Cebu, PWID are found to more likely undergo HIV testing and to know their test results than in other settings. However, among PWID eligible for ART, very few are actually enrolled in treatment. Although not condoned by national guidelines, several treatment hubs require from PWID that they stop injecting drugs before and during the course of treatment. Combined with limited access to CD4 count and possible injecting drug interaction with ARVs create obstacles to enrolment in and adherence to ART by this population.

25 26

IHSBB 2013 and AEM 2013.

2011 IHBSS

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The coverage of peer outreach targeting PWID with education for behavior change is very low, with Cebu slightly higher than other three sites but below 35%.overall. Fewer than 15% of male PWID have received free needles or syringes in the past 12 months, Needle sharing behaviour among PWID in all four surveillance sites remain popular, though slightly reduced from 67% in 2009 to 58% in 2011, about 90% sharing at last injection was reported in General Santos. Percentage of people who inject drugs who reported using sterile injecting equipment the last time they injected was 25%. The vast majority has never been tested for HIV.27 Percentage of PWIDs who last injected at the shooting gallery are high in Cebu (80%, 2011) and Mandaue (72%, 2011), which explains the highest HIV prevalence among the group, 52% for Cebu and 42% for Mandaue, respectively.28 Current HIV prevention among PWID is minimal, and the scale of harm reduction interventions –needle and syringe programme in particular—is insufficient to generate any measurable impact on the spread of HIV in this population. Needle and syringe programmes should be scaled-up considerably to achieve a coverage of at least 60%, as recommended by WHO.29 Recommendation 1.2a: The national surveillance for PWID should be strengthened by covering more of the National Capital Region (NCR) sites (Malate, Quezon City in particular) to detect epidemics early, while continuing to monitor the high level of needles/syringe sharing behaviour. Given the high HIV prevalence already detected in Cebu and Mandaue, it is urgent to initiate community based pilot projects of needle and syringe exchange, in line with the instruction of the Dangerous Drugs Board in collaboration with all local stakeholders in selected cities.

Attention and resources should be directed urgently to respond to the powerful HIV epidemic spreading among PWID communities. To this end, programmes and projects should be designed, monitored and implemented according to standards of Best Practice in HIV Prevention, Treatment and Care among Injecting Drug Users. Human resources at facilitybased service delivery sites for PWID should be increased and responsible staff assigned to comprehensive data collection and local use. Health service providers, law enforcement officers, prison staff, and peer educators should undergo further training on harm reduction.

Community and local stakeholders should be orientated and sensitized to PWID and HIV issues in order to secure their support to operational research on PWID service provision in Kamagayan Barangay. Needle and syringe distribution by peer educators in the community should be allowed, implemented, monitored and documented. Multi-stakeholders meetings should be held on a quarterly basis on PWID, with the participation of members of this community.

1.2b Men who have Sex with Men Men having sex with men currently bear the highest burden of HIV in the Philippines, but coverage for HIV services remains to be low. Over the last three years, more than 80% of the IHBSS 2011 IHBSS 2013 29 WHO/UNODC/UNAIDS (2012): Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users 27 28

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newly reported HIV cases were from male to male sex,30 with the national surveillance data showing that the average HIV prevalence among MSM in 10 sites rose from 1% in 2009 to 3.5% in 2013; city-specific data during the same period indicated even a more sharp increase in HIV prevalence among MSM from 1-7% in Cebu and from 1.4-6.7% in Quezon.31 However, prevention activities among MSM have been largely dependent on standalone Information and communication and/or behavioural change communication efforts. There were very weak linkages between peer outreach and HIV testing, STI and other services.

Current reach for peer education and outreach services for behaviour change among MSM are weak and in some instances not known. For example, in Cebu, only 2,500 MSM are reached out of the estimated 7,000 MSM while in Iloilo, the number of MSM has not been estimated. Peer educators have undergone training; they participate in monthly meetings and are supervised in theory by site implementation officers. These peer educators are temporary staff supported by the global fund or in some instance by the local government.

Peer educators supported by the global fund have a performance target of 7 MSM per month expected to have undergone HIV testing and returned for test results. Even with this low target, peer educators are unable to meet their target due to the modest return rate of MSM for test results. This may be attributed to the low quality of peer education, inappropriate choice of peer educators expected to engage with middle income MSMs, single Peer Educator encounter instead of repeat encounters, and low follow up rates. Peer educators are not supported by appropriate tools to be able to provide quality services.

Peer outreach is the right thing to do in order to deliver the prevention messages to MSM and promote preventive means, but it often lacks standardization and quality control mechanism.

The percentage of MSM exposed to interventions has not increased much over the years: the overall coverage remains at 23%.32 There is no sign that condom use during anal sex among MSM has increased, the rate fluctuated slightly over 30% during 2007-2011. In 2011, 35% MSM reported using a condom at last anal sex with a male partner. In 2011 as well, a mere 14% MSM had been tested for HIV and received test results. Another 8% were tested but did not receive the results. The majority had never been tested for HIV.33 Findings during the field assessment and observations were consistent with the surveillance surveys and other research findings, MSM engage with multiple sexual partners, both males and females; condom use is low; buying sex or receiving payment for the provision of sex services are also prevalent within the MSM population. Focus group discussions revealed that MSM frequently engage in receptive sex with clients self-identified as heterosexual men, and this often without condoms.

Stigma and discrimination keep the MSM and gay population at bay from health services and difficult to reach. Both actual and perceived level of stigma in health care settings is high.

HIV Registry Data 2010-2013, NEC, the Philippines IHBSS 2009-2013, NEC, the Phiippines 32 IHBSS 2011 33 (IHBSS 2007-2011), NEC, the Philippines 30 31

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Addressing stigma and discrimination, enhancing the appropriate clinical skills, knowledge, and sensitisation of health care workers, removing structural barriers to appropriate services delivery34, and increasing health seeking behaviours of MSM are also essential to programme success. Consequently, an increased proportion of MSM and TG living with HIV will realise their right to positive health, including access to existing public health ART services, lifesaving therapies, and targeted prevention and care through community programmes designed and run by and for MSM living with HIV, as well as the provision of clinical management of co-infections such as TB and hepatitis.

The review team noted that some interesting initiatives have open new avenues for greater outreach, these include: a) Internet based communication for MSM in Cebu although the number of MSM reached through this commendable initiative should be documented; b) Some Social Hygiene Clinics have adjusted their hours of operation to provide services dedicated to MSM, which include peer/outreach, VCT, STI and ART services; In these clinics, STI services are provided, but are limited to syphilis screening, syndromic management of urethral discharge is being provided while proctoscope examinations for anorectal infection screening are often not done; c) few NGOs provide services for MSM and drop-in centres are available in some cities, although the actual utilization of these services could not be evaluated; d) there is a cadre of young MSM professionals or middle income MSM that are not reached and are reportedly reluctant to utilize existing SHC and NGO services) VCT and ART services for MSM are often accessed and available free of charge; and f) among MSM seeking services at the Social Hygiene Clinics, the majority of those interviewed indicated that services were acceptable to them.

Recommendation 1.2b: MSM must be engaged more actively in delivering services, and peer outreach. Prevention activities must be adapted to the diversity of MSM sub-populations, including those living with HIV, and address sexual health needs through a variety of approaches and combinations of interventions best suited to the specific needs, demands and capacities of these sub-populations. Innovative use of mass and targeted media, including the internet and cell phone, should be integrated components in the delivery of prevention messages, health promotion and social support services. Commodities, such as condoms and lubricants, should be readily available and widely promoted. Prevention activities should be strengthened using a variety of channels and encouragement of local innovations, in locations where high risk behaviour may occur and include structural interventions. These should be included in a minimal package of preventive services, with strong linkages with HTC and ARV.

WHO-UNDP (2013): "Enhancing HIV, STI and other sexual health services for MSM and transgender people in Asia and the Pacific: Training package for health providers to reduce stigma in health care settings" 34

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In line with WHO-UNDP/UNAIDS recommendations,35 a minimal package for HIV prevention among MSM should be defined.

Prevention programming should also include sexual risk-taking linked to recreational drug use among MSM, as well as access to clean needle and syringes programmes for MSM who also inject drugs and the availability of prevention programmes for male-to-male sexual transmission in prisons and other closed settings.

Addressing stigma and discrimination, enhancing the appropriate clinical skills, knowledge, and sensitisation of health care workers, removing structural barriers to appropriate service delivery, and increasing health seeking behaviours of MSM are also essential to programme success. An increased proportion of MSM and Transgender individuals living with HIV should be able to fulfil their right to health through community programmes, including access to ART, clinical management of co-infections such as TB and hepatitis and other targeted prevention and care. Ideally, these programmes should be designed and run by and for MSM living with HIV. 1.2c Sex Workers and their Clients Sex work in Philippines is marked by the high volume of its transactions and its diversity. It has evolved from establishments where primarily registered entertainment-based female sex workers would meet clients to an expanding purchase of sex by male clients from freelance female, male and transgender sex workers who can be met on the street or through internet and cellular phone. Sex work is often associated with substance use, specifically alcohol consumption with clients and shabu, a slang term for the drug methamphetamine, sometimes mixed with caffeine, used in Japan, Hong Kong, Philippines, Malaysia and Indonesia.36 Prevention work among registered female sex workers in particular, revolves predominantly through social hygiene clinics. These sex workers pay for their HIV, syphilis and STI checkups and registration. These services represent an important source of revenue for the SHC although this money is reportedly forwarded to the local government administration.

Freelance female sex workers and male sex workers, who are at higher risk of HIV than their registered peers are insufficiently or not accessed by prevention services. Transgender sex workers are generally ignored. Although the 100% Condom Use Programme was mentioned during field visits in some of the social hygiene clinics, no clear operational guidance was readily available to the staff to implement this programme. Reported condom use among registered female sex workers over the last three years indicated slight increase since 2007, but still fluctuated around 80% or less; the usage rate is much lower among the freelance sex workers, fluctuating around 60% with no indication of improvement over the period 2007WHO/UNDP/UNAIDS (2010): Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: recommendations for a public health approach 35

36

Lianne A. Urada, et al (2013), Asia-Pacific Journal of Public Health

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2011 (IHBSS 2007-2011). Given the very low numbers of STI clinical or laboratory positive diagnosis, it was impossible to use this data to measure the impact of condom use. Yet, the risk of acquisition of STIs (and HIV) among registered sex workers was real: the reported rates of condom use with clients remained below target and sex workers declared not using condoms with frequent customers or with their regular partners.

Pink cards by SHCs as a form of protection for sex workers in establishments are used to certify that they were given adequate information on HIV/AIDS, STI and other diseases and that they are regularly screened for infections. Without an up-to-date pink card that can be presented to sex establishment’s managers or the police, registered sex workers can be suspended from work. A similar system of green cards also exists for free lance sex workers.

Donor agencies, governments and NGOs supporting HIV and STI prevention and care have long recognized the need for targeted national programmes for sex workers. Most programmes have focused on female sex workers with fewer working with male sex workers. While those working with male sex workers recognize that they are working with MSM, very few have specific programmes for transgender sex workers or collect disaggregated data on this population. To be effective, programmes would require a combination of peer outreach, risk reduction counselling, condom promotion, and provision of STI services. None of these components appeared to be fully functional in any SDC visited during the evaluation.

Recommendation 1.2c: Prevention Interventions for sex workers should be targeted/adapted based on local sex work patterns, local STI prevalence and policy environment. Social hygiene clinics should be better used to improve the services for registered sex workers; building partnership with sex work NGO and CBO’s to extend the scope of quality services to freelance female sex workers, male sex workers and transgender people. Interventions should incorporate inputs of sex workers and their community into how to make services user-friendly.

Sex workers are frequently exposed to HIV and other STIs, and have multiple risks for infection, including multiple sexual partners, barriers to the negotiation of consistent condom use and high STI prevalence. Sex workers are often not in a position to control these risk factors because of the legal, political and social environment, and the context in which they live and work, making them vulnerable to HIV and STIs. Based on a global systematic review of the past HIV response among sex workers, WHO, together with partners including UNFPA, UNAIDS and Network of Sex Work Project (NSWP) have crafted a set of evidencebased recommendations to strengthen the HIV and STI programme for sex workers in low and middle income countries.37 These provide ground guidance for a minimal package of HIV prevention for sex workers (male, female and transgender) in the context of the Philippines WHO/UNFPA/UNAIDS/NSWP (2012): Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low and middle income countries: recommendations for a public health approach 37

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1.2d Transgender people Prevention interventions specially targeting transgender people is non-existent, leave the group particularly vulnerable to HIV, transgender sex workers in particular. Transgender people have special health needs that have been severely neglected in Asia and the Pacific, same as in the Philippines. Transgender people are often included in MSM services, although their needs and expectations are often different from those of MSM. This is a neglected population at very high risk of HIV and STI infection. It is noted that an ongoing survey on HIV and syphilis prevalence as well as other health needs of transgender people has been conducted in Cebu, the results will be available by end of 2013 and used to guide planning and programming for essential services .

Recommendations 1.2d: A Transgender specific programme, informed by the forthcoming findings of a study being conducted in Cebu, should be created in consultation with transgender community representatives. Other project areas should also be more active in identifying transgender peer leaders as peer educator to initiate partnership between health services and transgender community. Health providers should receive orientation and sensitization on transgender issues and on how to stimulate the participation of transgender people in peer outreach and in the delivery of services.

In order for transgender people to protect themselves from HIV and other STIs, they must have access to the full spectrum of prevention services including information, sexuality counselling, HIV counselling and testing, as well as prevention commodities such as male and female condoms, lubricant and sterile injection equipment (to be used for hormone treatment or injection of other drugs).38 It is critical that substance-using transgender people be able to access support services if their drug or alcohol use becomes problematic and increases their risk of HIV transmission and acquisition.

It is desirable for transgender people living with HIV to seek early treatment for HIV, given the recent developments supporting HIV treatment as prevention (TasP). Similarly, it is important that other vulnerable transgender groups such as migrants and sex workers also have access to services that are sensitive to their specific needs. One of the consequences of stigma and discrimination in employment is that many transgender people have few options other than sex work to survive. This, in turn, has detrimental health consequences including the risks of HIV and other STI transmission, as well as violence, drug and alcohol use, anxiety and depression. Condom use is usually lower among transgender sex workers than other sex workers.

1.3 Condom promotion and distribution programmes Condoms are often provided free of charge to key population in GF-TFM sites, but lubricants are often not available. The social marketing of condoms for the general population is not WHO/UNDP/UNAIDS/APTN (2013): Joint technical Brief: HIV, sexually transmitted infections and other health needs among transgender people in Asia and the Pacific 38

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allowed in the Philippines; condom social marketing targeting key population is not actively implemented; condom promotion through the media does not exist; condom distribution at risky venues is not allowed, due to the barrier of local ordinances. Although supplied by the Department of Health to Social Hygiene Clinics, condoms are not always available or promoted in these facilities. Peers, volunteers and outreach workers do not always carry condoms or promote their correct and consistent use.

The 2011 surveillance round reported that only 65% of registered FSWs declared having used condom with their last client. This figure was significantly below the DOH target of 80%. Unprotected sex is rampant in all key populations and reported condom use remains low among populations at high risk for HIV and STIs. Condom use was extremely low among PWID: less than 5% in 2002-2005, and 20-25% in 2007-2009. Only slightly over one-third of MSMs used condoms with their most recent sex partner. Consistent condom use is a pivotal component of HIV prevention efforts since early days of HIV epidemic. Condoms, when used consistently and correctly, protect against unwanted pregnancy and the transmission of HIV and several other sexually transmitted infections (STIs).

Recommendation 1.3: A national condom strategy should be developed. Policies on correct and consistent condom use in sex work settings should be in place and the policies should be supportive of community empowerment for the work norm ‘no condom, no sex ‘. Condoms should be made available through a variety of channels: free of charge distribution, condom social marketing approach and involvement of private sector promotion. Condoms should be easily available and accessible for registered sex workers based in sex venues. Outreach activities should be scaled-up to offer free distribution of condoms and water-based lubricants to freelance female and male sex workers, MSM, PWID and transgender people.

1.4 Sexually transmitted infections The magnitude of the STI burden among most at-risk group is currently unknown. There are also no recent prevalence surveys on STIs. Few special surveys revealed that STIs are high among sex workers and men having sex with men. A STI prevalence survey among MSM in 2005 revealed high rates of rectal gonorrhoea (7.7% in Metro Manila and 10.8% in Baguio City) and rectal chlamydial infection (14.6% in Metro Manila and 18.4% in Baguio City). 39 A study conducted in 2007, revealed a Chlamydia prevalence of 17 to 32 % among registered FSW in Iloilo.40 Positivity rates for gonorrhoea and non-gonococcal infections from the Sentinel STI etiologic surveillance system (SSESS) have shown increasing positivity rates for gonorrhoea and non- gonococcal infections. This is only the tip of the iceberg, because screening of STIs among sex workers only utilize gram staining which is not sensitive or

Neilsen G, Epidemiology and Clinical Management of STIs among MSM. Family Health International, January, 2009 40 Saison F, Mahilum-Tapay L, Michel C. Prevalence of Chlamydia trachomatis Infection among Lowand High-Risk Filipino Women and Performance of Chlamydia Rapid Tests in Resource-Limited Settings. J of Clinical Microbiology. 2007. 45, 12: 4011-5007.

39

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specific for N. gonorrhoea and non-gonococcal infections.41 Syphilis testing, which have been done together with HIV testing have shown low rates among registered sex workers, but remain high among freelance sex workers and MSM. Rates of asymptomatic STIs are high especially among sex workers and MSM (monitoring data). It is therefore critical to screen for STIs in these key population. Screenings for STIs among registered sex workers have been on-going in the Social Hygiene Clinics as mandated by the Sanitation Code. However, Gram staining has a low sensitivity and specificity. Nucleic acid amplification test and polymerase chain reaction test for gonorrhoea and Chlamydia are being recommended for STI screening, but resources and laboratory capacity are limited.

Genital examinations are often not done properly to detect cervical infections. In most of the clinics visited, STI screening among MSM are not done routinely. No proctoscopic examination is being performed to screen for presence of ano-rectal infections. In some instances rectal gram stain is being performed among MSM. In HIV positive patients, the likelihood of having other STIs are high. However, most PLHIV are not being screened for STIs. In some area peer education has largely focused on the promotion of HIV testing and limited attention on education about STIs, recognition of symptoms and signs of STIs, encouraging regular STI check-ups or enhancing health seeking behaviours for key populations with STI syndromes.

There is also limited STI laboratory training among medical technologists in the social hygiene clinics, hampering the early and reliable diagnosis of STIs among clinic attendees.

Recommendations 1.4: Particular efforts should be made to improve the quality of STI screening among key populations. To this end, more systematic and optimal standards of clinical and biomedical diagnostic procedures should be enforced by periodically trained and retrained staff.

In practice, this recommendation requires specific approaches for each Key Population. For example: a) for sex workers: reduce the frequency of STI screening from 2 x a month to monthly check up, but improve the quality of STI screening procedure. It is essential to probe for any STI symptoms, perform a genital examination to determine the presence of signs of cervical infection and perform gram-stain adequately. A well performed examination and gramstaining will improve the sensitivity and specificity of the current algorithm. Extending screening frequency to the usual once-a-month for registered sex workers will reduce workload and increase time that can be spent for quality genital examination for free lance sex workers and MSM who are more likely to have higher rates of STIs);

41

Department of Health. Social Hygiene Clinics in the Philippines, 2010

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b) for MSM: encourage all MSM to undergo proctoscopic examination to detect the presence of ano-rectal discharge and ulcers. Use of gram staining for ano-rectal infection, is currently not recommended. It is essential to conduct a prevalence study on gonorrhoea, Chlamydia and mycoplasma genitalium for sex workers and MSM. This should also include the validation of the current algorithm for screening sex workers and MSM. Syphilis screening and HIV testing should continue to be offered systematically. All syphilis positive cases should be treated. In some set up the use of rapid test for Chlamydia which have low sensitivity and specificity and have not been validated, should be discouraged. It might be essential to explore negotiated prices for NAAT or PCR tests for gonorrhoea and Chlamydia test. Even costly in the short term, this approach might prove to be cost-effective in the long run. Medical technologists operating in SHC should benefit from regular proficiency training in STI laboratory diagnosis in addition to HIV testing. c) PLHIV should be screened for STIs. They should have a complete STI history taking and genital examination; d) Peer education should include a module on peer education on STIs, recognition of STI symptoms and signs and encouragement for regular STI check-ups and positive health seeking behaviour in the presence of STI syndromes. Sex workers should also be informed about the negative effects of douching on the reliability of vaginal swab testing; e) STI Etiologic Sentinel Surveillance (SSESS) should ensure that the NEC collate the data and provide feedback to the Social Hygiene clinics; conduct antimicrobial resistance monitoring of N. gonorrhoeae in selected sites, given the increasing resistance to Cephalosporins globally; and include urethral discharge as part of the SSESS as it provides a better indication of rising trends of gonococcal infection in men, whose infections are more symptomatic than in women.

1.5 Availability, accessibility, acceptability and quality of STI/HIV services Although services are acceptable to key population interviewed, there are areas where the quality of services should be improved.

Peer educators are being trained and are supervised to provide appropriate services.

However there is need for on-going support and for peer educator tools to improve peer educations. Peer education requires continuous quality improvement. Counselling services need to be improved. A checklist is available to guide counselling, but skills on counselling need to be improved. Clinic counsellors are often not available.

Prevention commodities are unevenly available: condoms are readily available but lubricants are often not. Laboratory reagents for syphilis, gram staining and HIV testing are being provided regularly by the Department of Health. STI drugs are available, based on the National STI guidelines. A couple of SHC served as satellite treatment hubs and were supplied with ARVs, but one SHC experienced several stock-outs. INH for TB prophylaxis is not available, since the TB programme does not supply it to SHC. Appropriate IEC materials suiting the specific needs of Key Populations are usually not available.

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Recommendations 1.5a Greater investment in Peer Education and other service delivery models apart from the Social Hygiene Clinic should be considered. Skills of peer educators should further be enhanced through regular training and supportive supervision from site implementation officers. Appropriate peer educators should be recruited, including adequate number of peer educators. (Develop eligibility criteria for recruitment and set criteria of number of peer educators over the number of KP e.g. 1 PE for every 50 KP.). Peer educators should perform microplanning to ensure systematic approach of reaching key population. They should have appropriate monitoring tools to track number of KP reached and repeat visit, services provided and required follow up. Develop training modules and job aides for peer educators should be developed and standardized.

Recommendation 1.5b In order to ensure availability of essential HIV prevention commodities, there is a need for a designated person at the national level to track stock outs of essential HIV prevention commodities. Guidelines on tracking stock outs could be provided by the Global Fund procurement focal point at the national level.

Recommendation 1.5c It is essential to maintain or improve coordination between SHC and NGO Peer Educators. Regular meetings should be held to discuss targets and issues on quality of services. The needs of MSM and PWID and acceptability of current services should be assessed, seeking suggestions on the best way to increase access and acceptability of services. The conduct of exit interviews of Key Populations using services and the conduct of Focus group Discussions among Key Populations not using these services should result in the design of new service delivery models aimed at to increasing access and use of services by MSM. Minimum standards of quality of service should be formulated along with monitoring indicators. The physical infrastructure of venues where services are provided (SHC and others) must urgently be improved.

1.6 Sexual and reproductive health and rights (including reproductive choices), contraception, fertility enhancement.

Like any other individual, key population and people living with HIV have sexual and reproductive health (SRH) needs and are entitled to the same reproductive health rights. The main concerns of key populations and PLHIV are often not just STI and HIV, but other reproductive health issues. For example, unwanted pregnancy or infertility can be critical issues among sex workers. As PLHIV are living longer and productive lives, some PLHIV express desires to be pregnant. Reportedly, women living with HIV are not discouraged by health care providers to plan a pregnancy. Information and advice are reportedly given them to make an informed choice about pregnancy, opting for PMTCT if they so desire. Whether these statements translated into practice could not be verified by the evaluation Team.

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Contraceptive counselling among PLHIV is being provided during post-HIV test counselling.

In addition, SHC are encouraged to provide contraceptive counselling to sex workers, but this is generally not done. In most of the treatment hubs and SHC, contraceptive methods are not readily available. Referral for contraception is being done to family planning service points.

Screening for reproductive tract cancers is often not performed. Transgender women, often need advice on use of contraceptives to enhance their feminizing effects. They should be forewarned about adverse events and side-effects associated with the use of hormones at high doses.

SRH needs are often overlooked, and it is important to expand services beyond STI and HIV to address these. Making SRH services available on-site or by referral will address broader needs of KP’s and PLHIV and increase their confidence and participation in the programme.

Recommendations 1.6: The following SRH services should be provided on-site or by establishing functional referral mechanisms: Family planning and contraceptive counseling; (promote dual protection for pregnancy, STI and HIV); ensure availability of condoms and if possible contraceptives at service delivery points for SW and PLHIV+; orientation of women to reproductive choices, safe pregnancy, abortion and post-abortion care and reproductive tract cancer screening (e.g. cervical , ano-rectal and prostatic cancers); and counselling on hormone use and referral to other gender enhancement practices for transgender people.

1.7 Populations living in confinement Prisons From an HIV and health perspective, the relationships between KPs and prisons operate in three ways, often in a cyclic and repetitive fashion. First, injecting drug users, Men having sex with Men and sex workers are more likely than other members of the population to be incarcerated, particularly when they combine two or more of the above attributes. These key populations may already be affected by HIV at the time of their incarceration. Second, during their stay in prisons they may be exposed to the transmission of HIV and other STIs through same-sex sexual contact. They may also be exposed to stigma, discrimination and violence during their incarceration. Third as a result of their sudden incarceration or transfer from one prison to another and on release to the community, interruption of treatment for HIV or related infections may occur, endangering people who are on treatment and exacerbating the risk of viral resistance to therapies. Prevention of HIV transmission is promoted in some prisons through the availability of condoms and some access to diagnosis and treatment of STIs. TB treatment is reportedly available to those diagnosed within the prison environment.

TB is diagnosed on the basis of history, clinical symptoms, chest X-ray and basic biological confirmation. HIV infection is diagnosed on the basis of voluntary HIV testing. The prison administration is well aware of its responsibility to provide health services to its inmates within its own budgetary limits. In the case of HIV, however, expensive ARVs are obtained by the prison administration from the DoH but this arrangement and others relating to HIV prevention, care and treatment of inmates, are informal, relying mainly on good relationship between prison officers and their local health counterparts. The prison administration has

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proposed to the DoH a joint agreement defining respective responsibilities in managing HIV. However, there is to-date no policy, Standard Operating Procedure or memorandum of understanding between the two branches of Government sealing such a cooperative agreement.

Recommendation 1.7a: It is recommended that a formal agreement between the prison administration and the Department of Health be formally approved in the form of a joint policy, accompanied by Standard Operating Procedures for the management of HIV within prisons and after transfer between prisons, addressing as well best practices in HIV/STI prevention and care and related supplies of medicines and commodities in detention facilities. It is further recommended that such procedures also cover the referral of inmates treated for HIV upon their release from prison so as to ascertain the continuum of care and prevention once they return to their communities. Civil Society Organizations ad more generally NGOs should be prompted and supported to play a key role in enhancing continuity of prevention, care and treatment for people in and out of jail.

Rehabilitation Centres Rehabilitation centres under DOH are known as Treatment and Rehabilitation Centres (DOHTRCs) and provide drug rehabilitation for 7 months for first timers and 9 months for repeaters. The location of the centre visited by the team was noted to be far from cities, where most of the residents came from. This government facility has a maximum capacity of 150 residents, charges 3,000 Php per month per person and requires a court order for admission. They are usually staffed by a nurse, social worker/ psychologist and house parents (former drug users).

The national policies and programs for HIV interventions in closed settings in the Philippines are yet to be formulated and there is no existing official local SOP within the centres. But certain centres have already initiated the implementation of certain strategies and programs in relation to STI and HIV. One of the centres the team visited has actively collaborated with Cebu City Health department in the conduct of regular education and information campaign on STI and HIV (every 6 months) together with HIV Counselling and Testing services. The centre also implemented baseline routine screening for Hepatitis B/C and Syphilis aside from TB. When needed, residents are referred to nearby health facilities where diagnostic and treatment services are available. The current practice on the management of HIV is for the diagnosed resident to follow up/visit the city health office on discharge. Information on HIV status of residents is, in theory, not known by staffs of this rehabilitation centre. However, current practice in the centre is to isolate residents with illnesses (i.e. HIV and others) and the reason for isolation is usually not confidential to other residents. Staffs in the centres are not trained to handle and respond to situations surrounding the presence of a resident known to be HIV positive. Despite the presence of post-after care services, the rate of relapse to drug use is reported to be high at about 90%.

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Recommendation 1.7b: There is a need to document current practices in rehabilitation centres where STI and HIV intervention activities have been initiated.

Such evidence could inform future policy and practices that could be generalized to all rehabilitation centres (private and government run).

Recommendation 1.7.c: The on-going STI and HIV related interventions in some rehabilitation centres need to be coupled with capacity building among staff, in particular on the handling of residents diagnosed with these conditions.

Recommendation 1.7.d Given the large and growing number of drug dependent residents outreach and open rehabilitation services providing psycho-social support should be explored and enhanced. The high relapse rate after discharge from rehabilitation centers should be taken into consideration in the evaluation of the design, implementation and effectiveness of the interventions and support services.

III. 2. HIV Testing and Counselling The Health Sector’s response to HIV has, over the years, emphasized the need for adolescents and adults to know their HIV status. Often seen as an entry-point into the continuum of prevention, care and treatment, HTC does in fact more than this. It is a means to ascertain whether individual behaviours have or not been protective against HIV infection and if referral to treatment services is required. But it is also a means to ensure that when PLHIV are on treatment, their own behaviours and practices are protective to themselves as well as to partners who may share their risk-behaviors. Thus, HTC is an integral part of the prevention, care and treatment continuum and this both on the individual and collective levels.

2.1 Promotion and uptake of HIV Testing and Counselling Whilst the government has done much to raise public awareness of HIV, it remains the case that targeted key populations campaigns, in particular MSM (text messaging; Take the Test) had limited coverage. Individuals from key affected population’s practical strategies are needed that challenge the low uptake of HIV testing and counselling. Indeed, campaigns targeting sub-populations within key populations (such as young MSM, TG and PWID) were very limited in scope. Sub-population campaigns are those that acknowledge that subcultures exist within “risk-groups” and may require different HTC promotional strategies utilizing different media, different linkages to preferred HTC services. The report “Health Sector Models to increase access to HIV Counselling and Testing (HCT)42 among Males who

42

The National AIDS Prevention and Control Programme in the Philippines uses the acronym HTC for HIV Testing and Counselling. Other partners in HIV prefer to use the acronym HCT for HIV Counselling and Testing. These two acronyms are used interchangeably in this report.

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have Sex with Males (MSM) in the Philippines (2012)43 notes that most MSM get information about HIV from friends and, in some locations, TV, radio, and SHCs. Certain subpopulations of MSM e.g. MSM who favor males exclusively, and those who are overseas Filipino workers or social networkers, or who know many other MSM) have higher risk behaviors but also better access to HIV services. By contrast, the reports notes that married MSM, and MSM who favor females or who know few other MSM, are at lower risk but have poorer access to services and information. It is further discussed in the report on that that young MSM, and high income MSM also have lower access to HIV services HCT throughput for MSM in general is grossly inadequate. Only 15% of MSM have ever had an HIV test, and only 5% were tested in 2012 and know their result44. Further, regional experience and focus group discussions conducted suggests “word of mouth” promotion of HIV testing and counselling is one of the most potent means of influencing uptake of testing and counselling45. However, the content of most peer education observed, or reported during this review consist of handing out referral cards, and using flip charts that contain basic HIV risk reduction messages, and advised people to take a HIV test. Peer educators are poorly prepared to engage in “one to one” discussions that allow them to explore and challenge barriers to uptake of testing and return for results.

Recommendation 2.1: Peer educators (PEs) require standardised training with skills rehearsal that enables them to ask if people have had a test, to explore reasons for not having had a test and to be able to challenge the client’s thinking and encourage them to take the test. Similarly, these training needs to ensure PEs also to sensitively enquire if people collected their HIV test results and without requesting to know the result) explore and challenge the reasons for non-return results.

2.2 Coverage and access In total 522 facilities offer HIV testing. HIV testing is offered through government facilities including social hygiene clinics (29) and hospitals, a limited number of donor dependent, non-government and community based services, and private medical clinics and hospitals.

The type of facilities vary widely from a simple clinic with one or more counsellors, with one medical technician using a single rapid test to large private laboratories that provide large throughput automated HIV Serology testing and CD4 and Viral Load (VL).

Whilst government, NGO and CBO services have employed counsellors, there is little evidence that private clinics and hospitals or laboratories offer any HIV test related counselling. At least 1.3 million HIV tests were performed in Philippines in 2012. However, the majority of these tests were not performed on individuals with the highest risk. For example, it is estimated 43

Health sector models to increase access to HIV counseling and testing (HCT) for males who have sex with males (MSM) in the Philippines. Dept. of Health, Republic of the Philippines National Epidemiology Center and World Health Organization Western Pacific Regional Office, 2012 44

Situation analysis and strategy for quality HIV testing and counselling within the context of the Philippine HIV epidemic Dept. of Health, Republic of the Philippines; the United Nations Children’s Fund Philippines, 2013 45 Samonte, G.M., Palaypayon, N., Segarra, A., Tayag, E., Nadoll, G. Integrating Most-at-Risk Adolescents into the National Integrated HIV Behavioural and Serologic Surveillance (IHBSS) in the Philippines. Poster presentation 2009 Vienna International AIDS Conference

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that there were more than 2.2 million Filipino nationals seeking to work overseas [overseas foreign workers (OFW)] in 2011 and most of these would have had a HIV test as part of their initial employment testing. This population is generally at low risk of HIV. The Social Hygiene clinics largely target and attract female sex workers and are underutilised by MSM and IDU. Service hours are restricted, clinics are overcrowded and clients complain of long delays in receiving services. Overcrowding at these services results from mandated weekly or bi-monthly check-ups and this make it difficult to envisage these services being ready to take on any increased demand for HTC. Often SHC clinics are not open at the times, or in the locations convenient to target populations. Discussions with unregistered male and female sex workers acknowledge a preference for attending private practices partly as the wish to remain unregistered despite having to pay more for this choice. HIV testing in private medical clinics or hospitals is not currently covered under Philippine Health Insurance.

Access to HTC for minors is a significant concern especially in an epidemic where younger individuals in key populations seem to be significantly at risk. The Philippines AIDS Law restricts access to testing to individuals below the age of 18 years old except consent is provided by a parent or guardian. The AIDS law requires voluntary consent to HIV testing, but parents or legal guardians have to provide consent on behalf of a minor. Imposing such age restrictions on testing except with parental consent resulted in less than 1% of high-risk males under 18 to ever have an HIV test a pre-requisite to seeking potential life-saving treatment and care46. Drawing on national consultations held in 2009 and 2010, further options to ensure adolescents’ access to HIV counselling, testing and related services were debated. In conclusion, lowering the age of consent for HIV testing to 15 years was included as part of the proposed amendments to the RA8504. The proposed AIDS bill, which was approved in principle by the appropriations committee of the House of Representatives in 2012, is still under consideration in parliament. Meanwhile as an interim measure to improve access to HTC minors DSWD is strengthening efforts to make HIV testing and counselling more accessible to adolescents under the current AIDS Law, by mainstreaming HIV in social work, capacitating local social workers, and revisiting the role of social workers in the consent process. Some counsellors and medical practitioners interviewed in this review acknowledged that they declined to test minors; some medical practitioners indicated that they provided consent on behalf of the minor drawing on their medical code of ethics to provide necessary care.

Recommendation 2.2: Expanding the available range and type of HTC models is key to improving coverage, access and entry into care. Innovative service models should be field tested such as private–public partnerships where sharing of resources such as counsellors provided by NGO or government funding with private service providers identified as being favoured by key populations. Additionally, the 46

Situation analysis and strategy for quality HIV testing and counseling within the context of the Philippine HIV

epidemic Dept. of Health, Republic of the Philippines; the United Nations Children’s Fund Philippines, 2013.

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expansion of service hours and the employment of different models of pre test counselling that require less time should be considered to alleviate congestion and improve both future increased demand for HTC and improve the quality of HTC in Social Hygiene Clinics. Innovative service implementation should continue, for example the referral to treatment hubs and enrolment of MSM who are community VCT clients after provisional diagnosis with receipt of two reactive results, from two different tests. Such approaches should be applied and replicated where these services can be monitored for compliance with DOH service standards. In order to improve access too necessary health care to minors it is imperative that there is immediate, strengthened advocacy for the revision of Philippines AIDS Law in respect to testing of minors.

2.3 Quality of the HIV testing and counselling process Over the first three years the of AMTP 5 The government has to be commended for having developed and later revised counselling curriculum, conducted HTC Master Trainer of Trainers training, and undertaken detailed reviews of both counselling and laboratory services, as well as planned and funded a serial testing algorithm validation study for point of care testing for key populations. Despite this considerable effort inconsistent quality and content of counselling, poor commodity management, a lack of equipment and the maintenance of equipment, and substantial delays in in the provision of results continues to hamper fulfilment of primary prevention and the treatment, care and support effort.

Pre and post HIV test counselling: Many counselling services were performed in areas lacking in visual and auditory privacy. During this review observers interviewed clients after counsellor consultations, directly observed provider processes and procedures using standard criterion checklists referenced against WHO and US CDC guidance on standards of practice. In many HTC services it was observed that clients left the HTC service without a clear understanding of the level of risks associated with different types of transmission risk behaviour and appropriate risk reduction methods being provided. MSM were rarely asked if they had female partners and rarely briefed on how to prevent mother to child transmission.

It is of considerable concern that direct observations of counselling sessions, staff and client interviews undertaken during this review revealed practise of predominantly NGO or CBO HTC counsellor practise of providing clients test results in a sealed envelope without first checking the results or requiring the client to show the counsellor the result. Further, many of the HTC providers indicated that it was the belief that they were “upholding the client’s right to privacy” that guided this practice. Is noteworthy that some of the counsellors also disclosed that they felt uncomfortable giving reactive screening or confirmed HIV positive diagnosis results to clients and this may also contribute to the counsellor’s desire not to learn the client’s results. Similarly, some of these counsellors also felt it was up to clients to disclose their status to partners and acknowledge that they either did not raise the disclosure issue, or simply informed the client that they should disclose. Few counsellors indicated that they had received practical skills training in facilitation of HIV disclosure.

Issues related to the quality of counselling provided to parents of infants and children living with HIV are discussed in the report in the section PMTCT and paediatric care.

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Recommendation 2.3 There is a need for DOH to develop a HTC quality monitoring and management system and assume a strengthened regulatory role. The HTC quality management program would assume responsibility for standardising pre and post test counselling training courses, ensure standard operating procedures are available for different types of service models (e.g. mobile or community-based VCT), and ensure standard medical record documentation occurs across government, non government and private HTC services. It is further recommended that in order to ensure appropriate, explicit and consistent health messages are delivered by counsellors, that counselling tools be developed that are specifically oriented to the needs of specific key populations. There is an urgent need to send out a circular or memorandum to all HTC service providers alerting them to their legal and ethical duty of care to check results before provision to clients to ensure that correct result has been provided to the client. Additionally, it is essential that HTC providers realize that they need to check client understanding of the results and implications for transmission prevention, and to facilitate linkages to treatment and care. There is also a duty of care to assess client’s ability to cope with an HIV positive result and where necessary address threat of risk of harm to self or others.

2.4 Counselling women in the post-partum and children Post partum counselling of HIV positive women Pregnant women recently diagnosed and those who have deteriorating health are especially vulnerable to depression. Positive women are also at increased risk of postpartum depression. Whilst most doctors caring for pregnant women and new mothers may have some training on recognition and management of post natal depression, most counsellors reported that they had not been trained to screen or manage this issue.

2.4. Recommendation: Depression not only reduces the quality of life of infected women but can contribute to poor treatment adherence, and to an inability to bond with, and care for, their newborn baby. It is imperative that counsellors are trained to aware of common signs and symptoms of depression.

Counselling of children and their parents Most counsellors, treatment enablers and SIO indicated little experience or training in counselling children living with HIV or their parents. Counsellors and community support workers reported grappling with complex issues such as what advice to provide to parents about “what and when” to disclose about their own health status to children, and “what and when” a parent should disclose to a child about their own infection.

Other concerns reported by families and their carers dealing with HIV involve interacting with the medical environment and addressing medical concerns. Families must negotiate financial and insurance difficulties and learn to communicate effectively with physicians and health workers. Additionally, they are coping with hospitalizations, clinic visits, and important medical decisions. Caregivers are often required to manage their children’s 65 | P a g e

medical condition as well as their own simultaneously, and possibly, that of other family members. The medical regimen associated with HIV can be notoriously difficult to follow for adults and more so for children. Providers interviewed indicated that it was important to address parental reluctance to take children for repeated painful blood tests and to ensure children take medication. Counsellors and support carers noted that they required training in this. Counsellors or support workers working with children noted their personal anxiety about approaching death and dying with children. Finally some counsellors noted that it was going to be difficult to manage the prospect of having to discuss safer sex with HIV positive adolescents.

2.5. Recommendation: Counsellor sand ancillary support workers working with parents and children require specific training addressing the issues of disclosure, preparation of children for clinic and hospital visits, and how to provide age appropriate counselling for HIV positive children and adolescents and their siblings.

III.3 HIV testing and Laboratory Support This section is an overview of HIV testing and testing facilities in the Philippines.47 It also reviews the testing of HIV in Key Populations (also referred to as most at risk populations, MARPs) and their usage of HIV counselling and testing centres (HCTS). The focus is on men who have sex with men (MSM) that use HCT as this is the group contributing the most new HIV cases in the Philippines and the entry point to care. However, this section expands to broader aspects of laboratory work supporting the continuum of prevention, care and treatment, pointing to several deficiencies that need be attended to ensure quality HIV prevention and treatment.

Information was collected from discussions with the Department of Health, Bureau of Health Facility and Services, National Center for Health Facilities Development, San Lazaro Hospital/STD-AIDS Cooperative Central Laboratory, WHO WPRO and country staff as well as various reports.

3.1 HIV testing and testing facilities At least 1.3 million HIV tests were performed in Philippines in 201248. However, the majority of these tests were not performed on individuals with the highest risk. For example, it is estimated that there were more than 2.2 million Filipino nationals seeking to work overseas [overseas Filipino workers (OFW)] in 2011 and most of these would have had a HIV test as part of their initial employment testing. This population is generally at low risk of HIV. Only 10% of the PLWHIV that were diagnosed in 2011 were OFW.(2) More than 522 HIV testing facilities including 29 Social Hygiene Clinics (SHC) operate in the country.49 The type of facilities vary widely from a simple clinic with one medical technician Section VI was prepared independently by Sandy Walker on the invitation of the External Evaluation of the Health Sector’s Response to HIV’ team and WHO as a valuable input to its report.

48 Correspondence with SACCL, October 2013.

49 Ibid 47

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using a single rapid test to large private laboratories that provide large throughput automated Serology testing and CD4 and Viral Load (VL). Many HTC services were observed conducting venepuncture in cramped, or high traffic areas, that offered little visual or auditory privacy, or afforded the opportunity of blood extraction without distraction and possible needle-stick injury. In the key informant workshop informants noted that at some sites staff reported that they were nervous or reluctant to perform venepuncture on PWID with extensive scar tissue. In response to questioning the some informants indicated that sites often did not have equipment such as “butterfly clips” to assist with blood draw. Some providers processing rapid tests complained that they did not have necessary equipment such as timers, and utilised instead mobile phones and were observed to have timed in between responding to SMS or taking calls. Some appeared to have relied memory of start times to process tests and did not adhere to recording start and finish times.

There are 35 HIV serology tests kits that have been registered and approved for use by the Food and Drug Authority (FDA). These include anti-HIV, Ag only, Ag/Ab combination test kits. In the 2012 SACCL EQAS for HIV serology testing, 477 participants used a total of 29 serology test kits (Figure 1). Rapid test kits were used by 66% of the laboratories. There are three HIV testing algorithms in place, one each for diagnosis of a client/patient; diagnosis of a neonate and for the screening of blood donations. There is no algorithm available for testing key populations. A specimen from an MSM or a person who injects drugs (PWID) is tested in the same way as a specimen from the general population.

The long turnaround time for provision of results ranging from 10 days up to five weeks or longer, is a major factor related to poor rates of return for results, and delayed entry into treatment among individuals from key populations, particularly MSM and PWID. It is noted in report prepared to compliment this review and confirmed by field observations and key informant interviews it was that there are multiple reasons for the reported delays and that these occur the different points along the sample processing continuum. Firstly, screening facilities employed ‘batch testing’ whereby they test multiple specimens in one batch to save resources rather than testing the specimen on the day it is received/collected. Reactive specimens then must be transported to the national reference laboratory SACCL and it is reported that this can be logistically difficult due to the geographical location of testing facilities and environmental factors. In addition, some couriers/airlines were reported to not want to carry blood specimens. As the cost of transporting specimens is covered by the referring laboratory facilities and many of these laboratories acknowledged that they send specimens in large batches this also contributed to the overall delay. This practice may also affect the integrity of the specimen and result in the client being required to undertake testing again. SACCL being the only facility that can conduct confirmatory testing – the maximum turn around time for reporting confirmatory results by SACCL is 10 days. All result reports sent to the HTC service in a paper result format and this further contributes to delay.

Additional concerns with the current algorithm relate to the cost of the Western Blot confirmatory test (WB). Whilst implementation of a serial rapid testing algorithm with provision for an immediate result is expected to virtually ensure receipt of results, this is reportedly unlikely to be implemented by 2015 and therefore interim strategies to improve 67 | P a g e

return for results and loss to follow up are urgently needed. Challenges relating to testing of neonates are reported under PMTCT paediatric care and treatment.

3.2 Reference laboratories There are two National Reference Laboratories (NRL) for HIV 

NRL – San Lazaro Hospital/STD-AIDS Cooperative Central Laboratory (SACCL) is responsible for conducting confirmatory testing in clinical (i.e. non-blood donor) situations for HIV, Hepatitis B, Hepatitis C and Gonorrhea. In addition SACCL provide External Quality Assessment Schemes (EQAS), test kit evaluation and training as well as services for the National Surveillance system mandated by the DOH.



NRL for Transfusion Transmitted Infections at the Research Institute of Tropical Medicine (NVBSP-NRL) provides services to the National Voluntary Blood Services Program (NVBSP). They are also responsible for conducting confirmatory testing for HIV, Hepatitis B and C, Syphilis and Malaria for blood donors; and provide quality assurance and training to Blood Service Facilities (BSF).

In some instances confirmatory testing is being performed by both SACCL and NVBSP-NRL for the same individual. For example, specimens from blood donors that are reactive are referred to NVBSP-NRL for confirmatory testing. Those that are confirmed positive and are able to be contacted are referred as a patient to VCT for screening. When the result is reactive the specimen is referred to SACCL for confirmatory testing. Additional duplicative activities between SACCL and NVBSP-NRL were also identified in the provision of EQAS. SACCL and NVBSP-NRL are both open to identifying opportunities to harmonise activities.

However, departmental orders require that both parties conduct testing in this manner.

The 522 facilities performing screening select the test kit/s from the FDA approved list that is appropriate for their facility and volume of specimens. Facilities use one only or a combination of two EIA or rapid test kits. Negative results are reported to the patient without additional testing. Specimens for which a reactive screening test was achieved are sent to SACCL for confirmatory testing.

SACCL perform two parallel tests that are of different formats: particle agglutination and an enzyme immunoassay. If both are non-reactive, then the result is released as negative. If the individual is high risk, then s/he is supposed to receive counselling, be taught preventive measures and be encouraged to have another test within 6 months. Specimens that are reactive or discordant in both tests are tested on a Western Blot.

SACCL is mandated to perform confirmatory testing under Republic Act (RA) 8504 Section.

There has been a large increase in the number of confirmatory testing specimens, currently between 380 and 480 per month. In 2012 there were a total of 4,443 referrals for HIV of which 78% were confirmed positive, 3% indeterminate. Nineteen percent of the referrals were false positive (negative specimens that were falsely reactive in the test(s) used at the screening facility).

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Concerns with the current algorithm relate to the delay between collecting a specimen and the reporting of results. The long turnaround time is a major reason for Key Populations, particularly MSM and PWID, not returning to get their result. The delay is the result of a combination of factors including:  Screening facilities often ‘batch test’ - they test multiple specimens in one batch to save resources rather than testing the specimen on the day it is received/collected  Reactive specimens must be transported to SACCL – this can be logistically difficult due to the geographical location of testing facilities and environmental factors. In addition, some couriers/airlines do not want to carry blood specimens. Moreover, the cost of transporting specimens is covered by the referring laboratory and hence facilities send specimens in large batches. This can result in specimens not being sent to SACCL for more than a month. This practice may also affect the quality of the specimen.  SACCL is the only facility that can conduct confirmatory testing, falling very short of the needs.

Additional concerns with the current algorithm relate to the cost of the WB. Reviews in 2011 and 2013 by the NRL, Australia at the request of the WHO and the DOH resulted in a recommendation to simplify the current algorithm and decentralize confirmatory testing into the regional laboratories. The new proposed algorithm would involve using rapid and other tests in prescribed combinations to eliminate the use of the WB. Briefly, screening laboratories would screen specimens using a test kit that they have selected from a list of test kits approved for screening. Specimens with reactive results would be sent to the regional laboratory which would conduct confirmatory testing using two HIV test kits that have been prescribed for confirmatory testing. This would significantly decrease the turnaround time for confirmatory results and be more cost effective than the current algorithm.50 The new three test algorithm must be validated before implementation due to the risk of false positive results owing to the relatively low prevalence of HIV in the general population in the Philippines. The plan to validate the new algorithm has been approved and funding was made available in 2013. SACCL will coordinate the project with support from WHO and NRL, Australia. It is estimated that the validation will be completed and the new testing algorithm recommended in 2015.

Eliminating the delay in the return of results would significantly improve the number of Key Populations that get a final test result and a HIV status. Recommendations for implementing a WHO serial rapid testing algorithm in HCT were made following a review in 2013.51 An algorithm providing for screening and confirmatory testing with rapid tests with an immediate result could be considered for use in the HCT settings in the Philippines.

However, the testing facilities would need to ensure they meet regulatory requirements such Report: Review and update of HIV testing algorithms for the Philippines, Sue Best, NRL Australia, 2011 51 Situation analysis and strategy for quality HIV testing and counselling within the context of the Philippines HIV epidemic, UNICEF Casey K, February 2013.

50

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as licensing; participation in EQAS; using only FDA approved kits for the prescribed purpose (screening or confirmatory); testing performed by a trained Proficient Medical Technician.

In addition they would need support, supervision and to have in place appropriate quality management system elements including as SOPs. Also, careful attention would be required to managing the balance between expiry date and wastage of the two confirmatory rapid test kits.

During the validation of the new HIV testing algorithm it will be determined whether screening and confirmatory testing could be performed using only rapid tests. The plan to validate the new HIV testing algorithm should ensure that data are collected to enable this analysis In October 2013 there was a WHO UNAIDS Regional Meeting on Community Based Testing.

The meeting discussed ways to improve access to HCT for key populations. The meeting suggested that rapid testing should be used in community settings. Two of the four testing models discussed included screening and confirmatory testing with rapid tests with an immediate result; these were recommended for the community setting. The meeting also recommended that MOH provide the appropriate support to community organisations such as funding and training in rapid tests. In addition, it recommended that MOH and community groups work together to monitor the quality of these services. It stated that personnel conducting HIV testing require training, must demonstrate proficiency and require ongoing support and monitoring of performance.52 Recommendations 3.2: In order to accelerate the availability of confirmed results and reduce poor return for test results, it is critical that the planned serial rapid test validation study proceeds as soon as possible. It is also critical to assess the available quality systems to support the implementation of a three rapid test algorithm for screening and confirmatory with immediate results in non-laboratory facilities such as SHC and community based HTCs as soon as possible. As an interim until the serial rapid test algorithm can be implemented, delays in provision of results should be shortened by extending the model service currently employed by community based services whereby the referral to treatment hubs and enrolment of MSM who are community VCT clients occur after provisional diagnosis with receipt of two reactive results, from two different tests. This approach should be replicated only where these services can be fully monitored for compliance with DOH in order to support quality testing. There is an urgent need to address the gaps in quality assurance of HIV testing. To this end, licensing, regulation of test kits, participation in EQAS and training should be considered. There is also a need to develop national training elements around the management and procurement of test kits and reagents. It is further recommended that the NRL extend EQAS schemes from one HIV distribution to two HIV distributions per year.

Draft ‘follow up’ joint statement and outcomes from the Asia Pacific Community Based Testing, October 2013 52

Regional Meeting on

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3.3 Nuclear Acid Testing (NAT) and CD4 testing There are at least four facilities offering HIV Viral Load (VL) testing, including the two NRLs and two large private hospitals. All use the Roche COBAS TaqMan HIV-1. Some large private hospitals offer Genotypic Drug Resistance testing. At least one reference laboratory uses PCR test for diagnosis in neonates. There are at least nine facilities offering CD4 testing, including the two NRLs and seven hospitals and medical centers that are funded by the Global Fund for AIDS TB and Malaria (GFATM). All are using the Partec instrument with the exception of NVBSP - NRL which is using the Becton Dickinson (Facscan) instrument. There may be a few additional tertiary private hospitals providing CD4 testing. NAT and CD4 testing fall outside the established quality systems that are in place to assure the quality of HIV serology testing.

For example, there is no licensing system for NAT and CD4 testing facilities. It is assumed that staff is trained by the supplier of the NAT and CD4 test kits and instruments. The limited availability of CD4 count facilities operated by trained staff is a bottleneck to the needed scaling-up of enrolment in ART. CD4 count is the procedure of choice for the planned scalingup of enrolment in HIV care and treatment below the threshold of 500 CD4+ cells per mm 3. A simple estimation should be made of the trends in CD4 testing facilities that would be needed across the country, taking into account: (1) Existing availability and replacement need of CD4 count instruments; (2) the rising trends in HIV VCT among Key Populations and the projected positivity rate of these tests; (3) the pace at which referral to CD4 count facilities will increase and the level of skills of the operating staff; (4) the optimal geographic distribution of CD4 count facilities to ensure rapid and equitable access, factoring-in the local HIV burden; and (5) the anticipated need for CD4 testing for monitoring purposes.

Recommendation 3.3a: A three rapid test algorithm for screening and confirmatory testing with immediate results should be considered during the validation of the new HIV Testing Algorithm. The available of quality systems to support the implementation of a three rapid test algorithm for screening and confirmatory test with immediate results in non-laboratory facilities such as SHC and HCT should be explored.

Recommendation 3.3b: CD4 count technology and operating skills should be scaledup to match the expected increase in HIV testing demands, particularly as the criteria for enrolment in care change.

3.4 Blood Safety The national HIV positivity rate in blood donations for 2012 was 0.15%.53 The proportion of Key Populations that donate blood with the aim of getting an HIV test has not been estimated. For MSM, it is known that this is occurring and this may be because MSM don’t know of, or want to use, available services such as SHC.54 Donating blood offered by persons Philippine HIV/STD Quarterly report 4th quarter 2012 Health sector models to increase access to HIV counselling and testing (HIV) for males who have sex with males (MSM) in the Philippines , DOH, NEC, WHO, 2012 53 54

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with the primary intent to know their serological status decreases the safety of the blood supply. This is of particular importance where the test kits used to screen blood donations are not NAT or Ag/Ab combination kits which lower the risk of missing positive donations from individuals in the window period. Donating blood to get a test result may also be providing MSM with a false sense that they are HIV negative. This is because it is BSF policy to not advise donors if they have a reactive test result. There is variation in the way this policy is followed. Some BSF believe that not advising donors of reactive results is unethical and may release results to donors with reactive test results55.

The Global Fund Round 6 HIV Grant recommendations state that hidden paid replacement donations are still collected and that this should be decreased.56 It is difficult to determine the experiences around this without visiting multiple BSF which is beyond the scope of this report.

Recommendation 3.4: It is recommended that the policy of not providing results should be made clear to donors. For example, signage indicating that HIV test results will not be given to blood donors should be clearly posted in the BSF. 3.5 HIV testing algorithm used for Blood Screening Blood donations are screened by BSFs for HIV, Hepatitis B and C, Syphilis and Malaria. Those that are negative are released for transfusion. Those that are reactive are sent for confirmatory testing to the NVBSP-NRL. The confirmatory testing algorithm used by NVBSPNRL is complex and includes five different tests including Ag/Ab combination EIA, Ab particle agglutination, Ag only EIA; automated Ab ChLIA and a Western Blot. NVBSP-NRL plan to include a sixth test, a nucleic acid test. NVBSP-NRL is in the process of conducting a retrospective analysis of data that have been generated from the strategy; however, this has been difficult as data critical to this analysis have are not collected The NVBSP-NRL is mandated to conduct confirmatory testing under the Departmental Order no. 393- E series 2000 and an Administrative Order No. 2005-0002. The number of donations requiring confirmatory testing has increased. In 2010 there was a total of 13,606 referrals for the five TTIs and 818 of these were for HIV. Of the donors that require confirmation, approximately 81% are confirmed as positive, 13% negative and 6% indeterminate. The majority of the confirmed positive donors come from mobile blood collections in metropolitan Manila.

Recommendation 3.5: It is recommended to review the orders that require NVBSPNRL and SACCL to conduct parallel and duplicate activities for confirmatory testing and EQAS. This duplication in activities undermines the efficiency and quality of the testing.

56

Evaluation report Global Fund Round 6 HIV grant Philippines 2007-2012

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3.6 HIV testing of neonates Diagnosis in neonates is complicated by the presence of maternal antibodies in the neonateâ&#x20AC;&#x2122;s circulation. The SACCL algorithm requires that a neonate has two positive PCR tests within 18 months to be given a HIV positive status. Some private testing facilities offer viral load tests for infants <18months. Caution should be exercised with this approach because manufacturers of viral load tests do not validate them for the purpose of diagnosis and specifically exclude diagnosis from their intended use. The results of these tests in neonates may be difficult to interpret reliably in the absence of serology.

3.6 Recommendations: The national program should review its algorithms in diagnosing infants <18months old. PCR testing should be centralized in SACCL only when it is used in diagnosing HIV among infants. The number of PCR in the country should be regularly reviewed with regards to the needs to start ART. 3.7 HIV testing for Key Populations and HIV HCT services In 2011, the percentage of MSM ever tested for HIV was 15% with only 5% being tested in the last twelve months57. Possible reasons for the low rate of testing were suggested by HAIN 2012, including: the general poor health-seeking behaviour of Filipinos; the cost of testing; the perception that MSM may be stigmatized in facilities; the perceived lack of confidentiality58. There is also a lack of awareness of HCT facilities with 47% of MSM saying they do not know where to get a HIV test;59 and an additional factor is the perception that SHCs are for sex workers. The 5% HIV testing rate in the last 12 months noted among MSM is within the range of testing practices among other Key Populations: in 2012, only 4% of PWID and 17% of sex workers reported that they had an HIV test in the last twelve months.60 MSM who are most likely to be tested are Overseas Filipino Workers (OFW) (137% more likely than other MSM), social networkers (21%) and those that have an income below the median value (11% more likely). MSM who are less likely to be tested include those <20 years of age (62% less likely than their older peers), those who know less than 20 MSM (25% less likely) and those who are married (18% less likely) than those who are not. MSM younger than 20 years of age are also 40% less likely than their older peers to return to get their test result61.

Minors, classified as anyone under 18 years of age, are unable to be tested without permission of a guardian. SHCs report that they are required to turn away minors who are

Health sector models to increase access to HIV counselling and testing (HIV) for males who have sex with males (MSM) in the Philippines , DOH, NEC, WHO, 2012 58 Health action information network/UNDP. Assessing the risk and vulnerabilities of Filipino men who have sex with men (MSM) and transgender people in three cities, Hain, 2012 59 Health sector models to increase access to HIV counselling and testing (HIV) for males who have sex with males (MSM) in the Philippines , DOH, NEC, WHO, 2012 60 Situation analysis and strategy for quality HIV testing and counselling within the context of the Philippines HIV epidemic, UNICEF Casey K, February 2013 61 Health sector models to increase access to HIV counselling and testing (HIV) for males who have sex with males (MSM) in the Philippines , DOH, NEC, WHO, 2012 57

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‘begging to be tested’. Lowering the age of consent of testing to 15 years was included in part of a proposed amendment to the Philippines AIDS law.62 Testing facilities used by MSM Some MSM perceive SHCs as a service for sex workers. Twenty five percent of the newly diagnosed HIV positives in 2011 were clients of SHC (with 25% detected equally in government hospitals, private hospitals, laboratory/clinic). MSM that are most likely to be tested in an SHC are those with an income below the median value (8% more likely). Social networkers are less likely (12%) and OFW are less likely (44%) to have had a test at an SHC. Most of the newly diagnosed cases come from a small number of the testing facilities. In fact, 45% of the new HIV cases diagnosed in MSM in 2011 were from 10 testing facilities. Twenty percent of new cases were from were from three SHCs located in Manila, Cebu and Quezon City. Data available by region show that between 2007-11 82% of new HIV positive cases were detected in only four regions: National capital region 54%, Region IV-A (Cavite to Batangas) VII Cebu 9% and XI Davao 7%,63 underscoring the urgent need to scale-up voluntary HIV testing and counselling among MSMs in other regions.

3.8 MSM not returning to receive results (loss to follow up) The IHBSS report suggests that only 65% of all MSM that have been tested received any result. Others estimate that, on average 81% of those MSM given a reactive result returned for the confirmatory result when the testing was performed by specific facilities. For those that did not return for results, the reasons given include the long turnaround time for receiving results; the quality of pre-testing counselling and the clarity around what a reactive result actually means. In addition, some subgroups show greater loss to follow up than others. For example young MSM <20 years old, are 40% less likely to return to get a HCT test result.64 A simplified algorithm that decreases the turnaround time from specimen collection to confirmed result would improve loss to follow up. ‘Start to finish’ tracking such as that used by the Love Yourself program could also improve loss to follow up.65 However, start to finish tracking may not be feasible on a national level.

3.9 Regulation, quality assurance and quality systems The Bureau of Health Facility and Services (BHFS) is responsible for licensing facilities that perform HIV testing. The process for licensing is with the BHFS for level 2 and 3 facilities and with the Regional Centre for Health Division for the smaller level 1 facilities. A licensed HIV testing facility must meet certain requirements such as: participate in EQAS, have at least one proficient medical technician and maintain basic laboratory facilities. A clinical laboratory must be headed by a Pathologist. Before a facility is awarded a license they are Situation analysis and strategy for quality HIV testing and counselling within the context of the Philippines HIV epidemic, UNICEF Casey K, February 2013 63 Health sector models to increase access to HIV counselling and testing (HIV) for males who have sex with males (MSM) in the Philippines , DOH, NEC, WHO, 2012 64 Ibid 65 Ibid 62

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inspected to ensure requirements are met. Renewal of registration is supposed to occur each year with the exception of blood services; however in reality this is not achieved.

An administrative order of the BHFS includes an exception for government testing facilities that conduct DOH programs, such as SHC which test for HIV and STIs. These facilities are not required to be licensed by BHFS. The administrative order does specify that facilities that are exempt from securing a license must adhere to program policies and participate in quality assurance programs. The DOH is responsible for managing these facilities and their requirements. The BHFS list the number of facilities that have a license to test HIV to be 546.

This list is not complete however and is an underestimate of the total number of facilities that are testing for HIV. It is part of a HIV testing laboratories licensing requirements that they participate in EQAS. However, there does not seem to be a consistent monitoring to ensure that all licensed laboratories participate. There is a well established programme for the pre-market evaluation, registration and regular renewal of registration of HIV Serology test kits (this does not include VL, PCR or CD4 tests). The processes are managed by the FDA and the technical aspects are undertaken by SACCL. Post-market surveillance is managed by a reevaluation of a registered test kit every two-years. These activities were reviewed in 2011 and recommendations for improvements were made. In addition, a review of the PME processes is being undertaken in light of the ASEAN harmonisation requirements.66 In 2013, SACCL provided EQAS to more than 500 testing facilities that conduct HIV testing for diagnosis and some BSF. Feedback to participants occurred in a timely manner, within one to two months of laboratories reporting results. Currently the EQAS is distributed only once per year however it is recommended that this is increased to two times per year.

Laboratory performances in 2012 SACCL EQAS Six of 477 (0.01%) of the testing facilities used a test kit that was not FDA registered. It is not clear how or why this occurs, but mechanism should be implemented that prevent it.

Twenty five of the 477 laboratories (5%) reported results in the EQAS that were aberrant. i.e. reported an incorrect HIV status for at least one specimen. Five of 27 of the aberrant results (19%) were false negative results which, in a real setting, would result in a negative result being given to a HIV positive patient.

Type of aberrant results that were reported in the 2012 SACCL EQAS Type of aberrant results False Positive (reported for negative specimen) False Negative (reported for positive specimen) False Inc./Ind.(reported for Positive specimen)** Other Total

No. of aberrant results 8 5 11 3 27*

*Two laboratories reported each two aberrant results **Inc â&#x20AC;&#x201C; Inconclusive; Ind â&#x20AC;&#x201C; Indeterminate

Report: Review and update of HIV testing algorithms for the Philippines, Sue Best, NRL Australia, 2011 66

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Facilities that reported an aberrant result are required to investigate the reason for the result and report back to SACCL what action they have taken to resolve the issue.

3.10 National Voluntary Blood Services Programme, National Reference Laboratories and External Quality Assurance System National Voluntary Blood Services Programme-National Reference Laboratories (NVBSPNRL) provided EQAS to some BSF prior to 2012. More BSFs participated in the SACCL EQAS (n=124 in 2010) than in the NVBSP-NRL EQAS (n=35 in 2010). Some of the BSFs participated in both programmes. The majority of the funding for the NVBSP-NRL EQAS was from GFATM. Feedback on the performance of laboratories or test kits was either not provided at all or was extremely late.

A fragmented system of two different EQAS (SACCL and NVBSP-NRL) is not recommended as it reduces the ability to detect problems in testing due to splitting data sets.

The National Center for Health Facilities Development (NCHFD) and the National Health Laboratory Network released in 2008 its first edition of the Manual of Standards on Quality Management System (QMS) in the Clinical Laboratories. The standard draws on some elements of ISO 15189 and can be applied to any clinical laboratory. NCHFD conducts QMS training programmes for government facilities using this standard. So far 74 laboratories have been trained, mainly at the district level. This programme may indirectly include a small number of facilities that test for HIV but will not have a great impact on the QMS in the majority of HIV testing facilities. There is no mandatory requirement for HIV testing facilities to have a QMS. Training of laboratory technicians SACCL and NVBSP-NRL are mandated to provide training for laboratory technicians. In 2012 SACCL conducted 13 training programmes in which 136 new medical technicians were trained. In addition, 253 medical technicians underwent re-training which is required every three years after initial training. The technicians were from 13 regions, 66% were from private and 34% from government facilities. The Proficient Medical Technician course includes HIV, Hepatitis B and C and Syphilis and is undertaken over 7 days. The training includes safety, waste management, test methodologies and trouble shooting, quality assurance and pre and post test counselling and other topics.

In 2010 NVBSP-NRL conducted three training programmes in which 74 technicians were trained. More recent information on training has not been provided by NVBSP-NRL. Recommendation 3.10: HIV testing facilities should be supported to implement quality management systems. Address the gaps in the national systems that support quality assurance in HIV testing; consider licensing, regulation of test kits, participation in EQAS and training. EQAS schemes should extend from one HIV distribution to two HIV distributions per year

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3.11 Test kits procurement A wide variety of HIV test kits are used in the country. Stock outs of rapid tests occur in multiple settings including hospitals, SHC and HCT. This is generally due to lack of financing and lack of appropriate demand forecasting 67 68 Other factors that influence stock outs are the inefficient internal processes operating within facilities. For example, government hospitals undertake a public bidding process when they purchase test kits (only test kits that are approved for use by the FDA are invited to submit bids). This process can take up to two months and internal ordering process can take an additional month. In some facilities the bidding process occurs once per year. It is assumed that frequent bidding processes ensure that test kit prices remain competitive. While this may be true, these processes as they are currently administered cause inefficiency, confuse testing statistics and confound the traceability of test results.

Programmes need to be developed to minimise stock outs; this has been suggested to be instigated at the national level. Training in forecasting and managing reagents and test kits could be included in the Proficient Medical Laboratory Technician training that is performed

by SACCL and NVBSP-NRL. In addition, each facility should have an individual that has been designated to be responsible for managing test kit and reagent stocks. The process and time lines around this should be documented in an SOP. Recommendation 3.11: The NASPCP should develop national training elements around the management and procurement of test kits and reagents. CD4 and viral load testing need be considerably expanded so as to remove the current bottle neck to increased enrolment of PLHIV in the treatment cascade. ; consider availability, coverage, uptake and cost Programmes need to be developed to minimise stock outs; each facility should have an individual that has been designated to be responsible for managing test kit and reagent stocks

IV.

Enhance policies for scaling up HIV programs

IV. 1 Lack of progress in monitoring the response The review team found that the AMTP 5 M&E area has suffered numerous operational challenges with coordinating and collating HIV related data from diverse sources. The process of developing AMTP5 was slow due to its multi-sectoral and decentralized nature and the lengthy procedure of consultation and approval by all stakeholders. It was adopted

Situation analysis and strategy for quality HIV testing and counselling within the context of the Philippines HIV epidemic, UNICEF Casey K, February 2013; 68 Health sector models to increase access to HIV counselling and testing (HIV) for males who have sex with males (MSM) in the Philippines , DOH, NEC, WHO, 2012.

67

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and largely disseminated in mid-2011. It was later translated into an operational plan through workshops.

The AMTP 5 has integrated a comprehensive M&E framework with many indicators that were deemed necessary to measure the numerous objectives and outputs of the 5 th AMTP that were unfortunately developed before the evaluation framework. That explains that some indicators are undifferentiated between those that measure outcomes and those that are more output or process oriented, and that some indicators are not always clearly linked to NSP objectives. The AMTP5 investment plan will need to be revised to adapt its frame to an epidemic largely concentrated in two high risk populations. The activities of sectors and agencies should be revised to address the reality of the epidemic. Plans of sectors should show how much they contribute to reducing the HIV among MSM and IDUs in prevention treatment and support. An update of the M&E framework will be necessary.

There have been no comprehensive national, provincial and district activity or investment plans that provide baseline and benchmarked targets against AMTP5 objectives and indicators. Instead, the few government departments that have HIV and AIDS activities included them within their own annual plans, and RAATS and LACs do not usually submit annual results-based plans despite several training and guidance given by PNAC in 2012 and 2013. Large training of RAATS and LACs in monitoring in the past 3 years have not yet resulted in improvement of M&E, including critical data on AIDS spending, with a few exceptions. Efforts should be pursued and templates developed for LACs and LGUs. There has been no annual multi-sectoral review process, so that a full overview of the multi-sectoral response is not possible. Efforts are only made in time for global reports every 2 years. This may mask the amount of activity by government departments and civil organisations at local level. Only the health sector is reporting against strategic planning targets.

PNAC does not have an M&E unit (only one devoted staff). There is no system for harmonizing indicators to be monitored or for coordinating and aggregating the M&E data across different departments and units. Some indicators have been introduced and expected by external donors (project based deliverables) from the country that were not in tune with the country indicators as articulated in the AMTP5. The reporting is fragmented as M&E is managed by the different agencies at various levels and by the different sectors, e.g. civil society and the Private Sector.

Monitoring, evaluation and operational research, and documenting best practices remain under-capacitated and underappreciated at all levels (national, decentralized government structures, civil society). Data quality is often poor and is seldom used for decision making or performance measurement. Periodic reports of LAC activities do not allow PNAC to identify gaps in the responses as well as best practices.

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The substantial effort and investment that have been made into improving M&E for HIV programs through RAATS have not lead to clear improvements. So there is no one place where the information on the response is being converted into strategic use by decision makers in various sectors to inform their planning and future investment. It is supposed to be DILG collecting and consolidating local response to HIV (governance) and forward it to PNAC Secretariat while the health response is being course through the DOH. The few sectors that have developed an investment plan were not funded by their institution/ agency which has created a feeling of fatigue. For some sectors, the concentrated nature of the HIV epidemic in the Philippines among MARPs, and more recently among MSM has questioned their contributing role to the HIV national response. In these challenging times, without clear focus, budget and sustainability, they feel disconnected from real problems associated with the spread of HIV infection. More issues and recommendations are found under PNAC capacity building, M&E systems.

Recommendations 1.1 PNAC will need to redefine the role and composition of its Board in order to be more responsive to the concentration of the HIV epidemic among MSM and IDUs and to fill the gaps in the response pertaining to these groups. The strategic information role of PNAC secretariat should be matched with an M&E unit with support staff and budget (in close relations with the DOH NEC) The M&E framework of AMTP5 needs to be revised and adapted to capture the HIV program activities of sectors and agencies at central and local levels. PNAC should be in a position to fund catalytic activities in the sectors directly relevant to the new HIV epidemic realities and, through MOUs, follow up the implementation of sectoral activities. At local level, PNAC should adopt a phased approach by extending direct M&E support to LACs and LGUs in selected priority settings. Based on city investment plans, M&E templates should be developed for LACs and LGUs. The M&E links between LACs and PNAC should be strengthened.

IV. 2. Ensure national investment commensurate with HIV cases and more targeted to the groups most at risk 2.1 AIDS response underfunded In October 2013, an opinion survey was conducted by the Review team among 74 stakeholders; to the question about how satisfied they were with the way the national response is funded, 57% reported to be very unsatisfied or unsatisfied (see Annex 2).

Data from NASA covering 2009 to 2011 estimated AIDS spending at about 12 million dollars per year over the period, with a marked increase in domestic spending -public and privateand a significant reduction of international contribution69. According to all international 69

Strategic information brief: AIDS Investment, UNAIDS 2013

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standards, the national response still remains largely underfunded70. The investment plan of PNAC recommends a minimum of 27-30 $US million per year for the next 3 years (with a focus on 40 A and B priority areas)71. Current discussions both by the PNAC and the congress revolved around increasing the current budget to about 12-13 million $US per year.

Full funding of the AMTP 5 was never considered. A substantial increase in spending for AIDS in 2014 is foreseen, with a budget of about 7.5 million dollars for the Department of Health.

From 2009 to 2011, the government has only slightly increased its domestic resources for AIDS-related work. The provincial and district budgets also increased slightly during the same period as well as the investment from the different agencies and sectors members of PNAC. But the total amount spent is still far from what is required in order to respond adequately to the HIV epidemic. An important challenge for PNAC is how it can advocate for increasing domestic support for the national response to the growing epidemic. Strong political will is required to reduce dependency on external financial assistance to control HIV and AIDS. Funds made available for 2012 were estimated to be US$10.6 million. The private sector contribution was excluded after 2011. Indeed, the bulk of the expenditures from private sources came from DKT Reproductive Health, Inc. an international company targeting mainly family planning users, and hence not HIV and AIDS specific.

Of this budget for 2012, the Global Fund covered the bulk at 42%. The rest of the allocations were from the national programs (22%), local government (19%), and bi/multilateral agencies (17%). Spending from public sources increased given the higher budget allocation from the Department of Health (DOH), as well as for Department of Social Welfare and Developmentâ&#x20AC;&#x2122;s (DSWD) mainstreaming of social protection-related activities.

However, in 2011, the contribution of other sectors than the Department of Health was negligible, with exception of DSWD, showing that the Philippines are far behind the implementation of a multi-sectoral response. One reason is that HIV and AIDS are still Global AIDS Response Progress Report, 2012; National AIDS Spending Assessments (NASA) 20002012 71 2011-2016 AMTP5 Investment Plan 70

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perceived as a health problem, with the Department of Budget Management (DBM) not allowing easily other ministries to have specific activities on HIV. The implementation of the HIV workplace policy in all government sectors as planned for next year may improve the commitment of government sectors outside of the health sector. However, investment plans of key sectors need to be updated or developed, and mainstreamed.

2.2 Resources should be allocated more strategically In 2011, the program management budget was about 25% of the total spending on AIDS; the spending on HIV prevention represented 64% of the total AIDS spending but programs targeting most at risk populations, including VCT and STI management, represented only about 18% of the total AIDS spending. Of the total AIDS spending, about 4% were spent on MSM targeted interventions, including a small fraction for PID. 14% went to HIV prevention among female sex workers, for whom there is higher uptake of services, including management of STIs. This spending pattern does not match the HIV epidemic pattern. Less than 5% of the total AIDS spending goes to the population groups where about 86% of new HIV diagnosed cases were found in 2013. The rest of the prevention spending was on programs with low impact for the general population such as general communication for social and behavior change, as well as blood safety. This figure calls for a very significant rise in HIV spending for MSM and IDUs but also for more efficiency in the management.

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Total AIDS Spending by function, 2011 (NASA)

In addition, most interventions for HIV prevention for MSM and IDUs are not funded by public funds. The expected lower contribution of Global Fund72, the gradual reduction of donor support for HIV programming, exacerbated by the recent economic recession highlight even further the importance of improving the optimum use of available funds.

In order to clearly reflect the coverage of donor supported programmes and the duration of their support, there is need of a strong mechanism in PNAC and NEDA of tracking of resources to ensure the continuity of ongoing preventive programmes for MARPs. As an example, 17 of 23 sites of the 2008-2012 GF Round6 grant were not continued in the 20132014 GF-TFM grant. None of these sites had developed plans to sustain earlier investments on AIDS. Actual costs of a prevention package per year per MSM/PWID was estimated at US$170 73.

Recommendations 2.1 and 2.2 PNAC, DOH and development partners should increase coordination and harmonization to maximize resources available. Gains in efficiency should be made by reducing program management cost and by re-allocating funds to prevention programs for MSM and PID. More advocacy and resource mobilization should be undertaken by PNAC & DOH to increase domestic investment, particularly within government sectors and to reduce dependency on external sources. The oversight role of the Philippine Congress on the National HIV response that define the PNAC budget should be strengthened with PNAC reporting once a year about the results achieved. The oversight role of CSO also needs to be strengthened to continue advocacy for funding AIDS response and monitoring government utilization of investments in HIV to deliver results.

72 73

Global Fund. Transitional funding mechanisms. Philippines CCM proposal, 2012 Philippine HIV costing study: selected HIV prevention and treatment services, 2012

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National spending assessments should be a priority for PNAC to help guide implementation of AMTP5. Spending assessments should also be conducted at the City level to allow for a more in-depth analysis of AIDS expenditure and support strategic policy and programme planning. NASA assessments, at city and national level, should be made public to ensure accountability and to identify gaps in resources in city investment plans. The NASA findings should be more broadly disseminated by PNAC among key national and international stakeholders to ensure their use.

IV. 3 Progress in laws, policies and guidelines to support comprehensive HIV programs 3.1. Promising development but unfinished agenda Over the years, major constraints to implementing effective HIV prevention interventions in the Philippines were associated with either absence of supportive laws and/or presence of punitive laws that impact negatively on the scaling up of the national AIDS response among MARPs. New policy and legislation addressing specifically the stigma and discrimination against MARPs, and harmonization of some provisions of the AIDS Law with other laws needed to be provided. In October 2013, an opinion survey was conducted by the Review team among 74 stakeholders (ANNEX 2). To the question about the 3 major factors that are obstacles to an effective response to HIV, the most common responses were: stigma and discrimination (17%), policies and laws (14%) and the lack of community centered design and delivery (14%).

The progress in laws and policies environment since 2010 was substantial, with civil society and community organizations at the forefront with PNAC support. However, the agenda is unfinished. Outside of the health sector, where important technical guidelines were newly developed, a series of memorandum were issued that gave an impetus to a multisector national response. Below are selected examples of policy support to HIV prevention in the workplace, to the institutional response, to care, treatment and support, as well as the removal of non supportive laws.

1 2 3 4 5 6

Selected policies and laws HIV in the workplace policy Memorandum to request all cities to create Local AIDS council and define membership The Referral System for the Care and Support Services for PLHIV OHAT- The implementation of an outpatient HIV/AIDS treatment package Access to Cheaper Medicines Act, inclusion of ARV as part of the list of Phil essential drugs Anti-discrimination bill also protects individuals against discrimination

Source CSC DILG DSWD PhilHealth Law Law

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7 8

based on HIV status.

The Responsible Parenthood and Reproductive Health Act The revision of AIDS Law, RA 8504

Law Law

For example, (1) the HIV workplace policy of CSC, creating a set of new rules on HIV education, services and referral systems for all government employees have been followed by a series of Department orders. The Guidelines in the implementation of Workplace Policy and Education Program on HIV and AIDS, issued by Civil Service Commission (CSC) MC11, 2013 have been followed by a series of Department orders (Memorandum) on HIV and AIDS prevention and control program in the workplace policy, in the Departments of Labor and employment (DOLE), of tourism (DOT), of the Interior and Local Government (DILG), of foreign affairs (DFA) of Justice (D0J) and of Education (DepEd). This creates a set of rules on HIV education, services and referral systems for all government employees. Some departments have also developed a road map to operationalize their workplace policy on HIV (e.g. Dole and DOJ); the Department of Education has issued a memorandum for the acceleration of HIV education among teaching and non teaching personnel in identified HIV hot-spots (DepEd, DO 47).

An important memorandum of DILG issued in April 2013, the Strengthening Local Responses Towards More Effective and Sustained Responses to HIV and AIDS, MC29 (2) enjoin all cities and provinces, to create Local AIDS council (LAC) to help Local government units (LGUs) in planning, programming, budgeting, and implementing HIV and AIDS activities. This memorandum defines the structure and membership of LACS and the institutional links to the Regional AIDS Assistance Teams (RAATS). It also stresses that one of the objectives of LAC is the protection of the rights of PLHIV, the elimination of stigma and discrimination and the promotion of confidentiality.

In the Treatment, care and support area, (3) The Referral System for the Care and Support Services for PL HIV was a significant program tool that should facilitate the collaboration of service providers and local government agencies to provide care, and support for PLHIV. The DSWD developed a referral system that has equipped LGUs with the necessary mechanisms to deliver community based services to PLHIV. Furthermore, this Referral System will also ensure that social workers and other service providers will be guided by the principles of confidential HIV counseling. A critical step for the guarantee of the sustainability of access to ART for AIDS patients and PLHIV has been taken by including an ART treatment package in the Philippines national health insurance (PhilHealth). In 2010, PhilHealth has approved the implementation of (4) an outpatient HIV/AIDS treatment package (OHAT). This benefit aims to increase the proportion of the population having access to effective AIDS treatment and patient education measures. OHAT benefit Package will be paid through a case payment scheme. The annual reimbursement is set at 30,000 pesos per year. PLHIV can also access PhilHealth package that includes HIV screening and other laboratory expenses. The recent Access to Cheaper Medicines Act (5) ensures lower prices for ARVs and gives access to TRIPS flexibilities.

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(6) The anti discrimination bill -still pending- prohibits mandatory medical procedures, including HIV testing.

Two other major policy developments for HIV prevention are still pending in the legal system but with good chances to be adopted in 2014, if pressure continues. The first (7) is the Sexual Reproductive Health law, a decade old Bill, which will enhance education on sexuality, reproductive and sexual health, including HIV, for young people.

Much improvement is also expected from the Revised Philippine HIV and AIDS Policy and Program Act of 2012, amending the AIDS Law RA 8504, (8) still pending in both House and the Senate. All together, these policy frameworks are potentially providing a powerful enabling environment for the response, if implementation is effective and closely monitored.

Indeed, the “Philippine AIDS Prevention and Control Act” of 1998 has served as the legal framework of the national AIDS response in the country. As much as this AIDS law was supportive of general measures to fight against stigma and discrimination, and provide access to services and commodities needed for HIV prevention and treatment, care and support, after 15 years, the need to adapt this legal framework was more and more felt, in lights of the changes in the HIV epidemic.

The new Law will restructure the legal framework on HIV and AIDS by harmonizing it with evidence-informed strategies and approaches (e.g. opt out HIV counselling and testing, positive prevention…). Many improvements in the AIDS law are noticed by explicitly addressing the way other laws are enforced: e.g. the prohibition on the use of condoms, and sterile injecting equipment as a basis for raids and similar police operation. It clarifies the roles and responsibilities of institutions involved in the HIV and AIDS response, from government national agencies to the local level. The bills strengthen the Philippine National AIDS Council (PNAC) as the central planning agency for HIV and AIDS by increasing its functions and providing a permanent secretariat to support its activities. It clarifies the mandates and functions of PNAC Secretariat from DOH-HIV and the AIDS prevention and control program. The amended AIDS laws also highlight the “protection of and promotion of human rights as cornerstones of an effective response to the HIV epidemic”. It also strengthens stigma reduction mechanisms and establishes the rights of an individual to file a complaint directly to the Department of Justice for any form of HIV discrimination. Penalties are provided for violations of the provisions of the law and its implementing rules and regulations. The bills also establish a Congressional oversight Committee to report on progress in implementation. These bills have “a good chance to move forward” before the end of the AMTP 5.

Removal of harmful laws on the way The revision of the AIDS law, if passed, will remove many non supportive HIV policies that were barriers to current efforts in HIV prevention. The Comprehensive Dangerous Drugs Act (RA 9165), (1) which prohibit the distribution of clean needles and injecting equipment will be amended to allow the implementation of a program of harm reduction in Cebu. The family and sanitation code(2) that restricts the provision of information and services to people

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most at need including young people under 18 will also be amended to allow access to HIV testing for younger people under conditions. Other laws being used by the police to harass and extort money from MARPs, particularly LGBT, include the Anti-trafficking law (3) and the anti-public scandal law (Revised Penal Code Article 200), RA (4) or other ordinances intended to promote “public order”. The anti-poor vagrancy law (RA 10158) (5) has been abolished. Human rights, community organizations reports and local reports by LACs consistently show that the interpretation of these laws have directly affected HIV prevention programs.

1 2 3

4 5

Legislation and policies (Dangerous Drugs act of 2002 (RA 9165 ) – will allow the implementation of a “Harm Reduction Program” RA 8504 and family code– will allow some HIV services like HIV testing to younger age group RA 9208 – “Anti Trafficking in Persons Act of 2003” – the new law decriminalizes sex workers but not clients and establishments The anti-scandal law (Revised Penal Code) can no more be used to arrest MSM and TGs The anti-poor vagrancy law (RA 10158)

Status Pending revision Pending revision Pending revision

RA 8504 RA 8504 RA 8504

Amended Abolished

Other important policies and guidelines In 2010, the Department of Health has developed a new Strategic framework on the HIV response on children and young people that was incorporated in AMTP 5. The National Strategic Plan for Men having sex with Men (MSM) and Transgender Populations 2012-2016, and its operational framework were endorsed by government and included in AMTP 5; The Department of Health has also issued new guidance on VCT (2010), on the new roles and tasks of the Social and Hygiene clinics (2010).

In 2012, The Department of Budget Management (DBM) has defined in a circular “guidelines on the participation of CSOs in the preparation of the budget government agencies”. Although the circular is about all budgets (not HIV specific), the DOH has invited NGOs and PLHIV for the preparation of its budget in 2012.

In 2011, one major resolution of PNAC has been the Approval of operation research for harm reduction in Cebu. This limited research project on Harm reduction for PWID opens possibilities for a future implementation of evidence-based HIV programs targeting PWID in selected sites. A draft policy guideline on drug harm reduction has been developed.

In 2011, in a specific effort to accompany the AMTP5 strategic plan with a road map for its partners, PNAC has developed key instruments to operationalize the plan such as the AMTP5 Costed Investment Plan and a costed monitoring and evaluation plan. Three sectors -DOH, DOLE, and DSWD – drafted investment sectoral plans but only the DOH plan was fully funded and is implemented.

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An agreement with CBCP on common ground for Catholic Church support on HIV issues was reached that should further facilitate the engagement of religious groups in HIV, especially in PMTCT and care and support.

Local HIV policies in the format of ordinances at the level of LGU have developed rapidly. According to UNDP, the number of local policies has increased from 44 in 2011 to 171 in 2013. This rise is associated with the generalization of Local AIDS coordinating mechanism: from 99 in 2011 to 742 (including cities and municipalities). The content of the local policies and ordinances covers a range of issues. For example, legislations prohibiting discrimination on the basis of sexual orientation, gender identity and health status have been approved in the key cities of Cebu and Davao; the city of Davao issued an ordinance for requiring entertainment establishments to have at least one peer educator; in Pasay city, an ordinance requests lodging places and entertainment establishments to provide free condoms for its clients; Quezon City set an ordinance that prohibits employers from discriminating against their workers who have or are believed to be infected with HIV. The review team notes that the emphasis on the content of HIV policy is in sharp contrast to the lack of attention in the past to how these policies can be operationalized, implemented and sustained. To put it differently, in some areas, addressing the risk of HIV transmission was done through legal approaches rather than enhancing HIV services and educating people at risk. In addition, the content of the policies was not necessarily enforced. Forward looking means for PNAC to focus on how the new bills and ordinances can be operationalized especially in areas that directly affect HIV prevention, such as needle exchange programs and condom promotion.

Recommendations 3.1 PNAC should play a more active role to disseminate new HIV policies and guidelines and to facilitate their implementation. PNAC should provide leadership and guidance to sectors & implementers on how the new HIV bill and the other laws can be promoted, operationalized, implemented and monitored. While the new HIV law is pending, PNAC & DOH should prepare a national HIV prevention policy to include promotion/provision of commodities such as condoms and needles. PNAC should strengthen its support to LACs & LGUs in the development of HIV ordinances to remove obstacles to the local HIV response (e.g. police raids). PNAC and civil society organizations should also give more central support to LGUs who are experiencing law enforcement abuse, arising from arbitrary interpretations of existing policies.

3.2 Discrimination and social stigma The current experience of discrimination and stigma among PLHIV is a major obstacle to any public health intervention among MSM: the weak uptake of HIV testing and counselling is the most obvious result of the fear of LGBT to face the results of HIV testing. Preliminary results of a recent study by Pinoy Plus74 among a large representative sample of 1320 PLHIV show 74

Pinoy plus. Stigma and discrimination among PLHIV in the Philippines, unpublished 2013

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low levels of institutional discrimination in health services and schools. Housing and physical violence is more a concern for women living with HIV. There is a high level of social stigma perceived by TG, female and male PLHIV, reflecting on the fact that among the general population there are still unfounded fears, high levels of misconception about how HIV is transmitted, and biased moral judgments. Verbal harassment was reported by 8% of respondents but 16% of TG. Exclusion of social gathering and activities was reported by 23% of males and females but 37% of TG. The review team also found evidence of multiple stigmas associated with LGBT orientation and being HIV-positive.

There are policy actions that will strengthen protection against discrimination for PLHIV. The amendment of the AIDS law will put in place improved mechanisms to handle discrimination complaints. The new anti-discrimination bill specifically includes protection of the human rights of PLHIV. The review team noted that, since 2011, only about 10 complaints have been brought to the attention of PNAC secretariat and DOJ and that were solved through informal processes. The major reasons why PLHIV have not sought legal redress include are the unwillingness to be exposed publicly as HIV positive, the lack of knowledge of PLHIV rights; and the perceived high cost of legal actions. There is a divided opinion on mechanism to record, document and address cases of discrimination experienced by people living with HIV and/or most-at-risk populations. PLHIV community is hesitant to seek redress on grounds of discrimination because of the stigma attached to being HIV positive. Three hundred members of the judiciary have been trained/ sensitized to HIV and AIDS and human rights issues that may come up in the context of their work. The review team has found that among various judicial agencies, the Commission of Human Rights (CHR) is best placed to play the central role of handling human rights violations of PLHIV. CHR can investigate cases without disclosing names and resolve them through mediation or recommend further legal action.

Recommendations 3.2 Fighting stigma and discrimination against hard to reach populations and PLHIV is a critical enabler and concerns all stakeholders and sectors. PNAC and DOH should continue to empower MARPs and build the capacities of their networks. The health sector, both public and private, has a particular responsibility to protect human rights of PLHIV, especially in guaranteeing confidentiality. Engaging accredited PLHIV as counselors should be a first step in this direction. Human rights literacy training of PLHIV should be an integral component in community level mobilization.

PLHIV networks should educate their members about their rights, especially about HIV testing and confidentiality. Promotion of acceptance of PLHIV and advocacy on non-discrimination should be part of media campaign, school education curriculum, community and work-based initiatives. The Commission of Human Rights should be officially designated as the locus for the handling HIV-related human rights violations and complaints.

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V.

Expand capacity of PNAC

V. 1 Capacity of PNAC strengthened to perform the function as the central advisory, planning and policy making body of the national response.

1.1 Human and financial resources The national response is coordinated through the Philippine National AIDS Council which acts as the highest advisory, planning and policy-making body on AIDS. It is composed of 26 government agencies, NGOs, professional organizations and representative from people living with HIV. It is in charge of planning, coordinating and monitoring the country’s national response to HIV and AIDS. It ensures that all HIV and AIDS projects and initiatives in the country respond to or harmonize with the AIDS Medium Term Plan.

PNAC is supported by a Secretariat whose functions is to support PNAC plenary in its policy-decision making, insure availability and utilization of strategic information for program planning, coordination and monitor implementation of sector-specific responses and provision of administrative support to PNAC. Assisting PNAC in the management of various aspects of AIDS prevention and control are sector-specific clusters of member agencies—health, labor, education, social welfare, local governments, foreign affairs and civil society.

Operationalization of the AMTP 5 No actual workplans were finalized to operationalize the AMTP 5, thus, annual performance targets were not determined including resource mobilization requirements. An operational planning workshop was organized in January 2011 attended by the heads and members of the existing Technical Working Committees and the Secretariat staff but expected outputs were only partially delivered. Most member agencies remain to this point, without a clear sector-specific, HIV strategic and annual operational plans and budgets and thus, no periodic monitoring or tracking of progress made in their contribution to the national response.

Moreover, member government agencies are still confronted with the perceived absence or lack of mandate to undertake HIV-targeted programs, projects and activities by the DBM that approves its annual agency budgets. Persistence of such issue is attributed largely to either the lack of internal advocacy within and among the Council (DBM being a regular member of the Council) or the lack of imagination among Council members in innovating means to mainstream or institutionalize HIV-specific plans in their regular menu of programs and services. A high level of disgruntlement, exasperation or cynicism has been expressed by informants insofar as getting Council member agencies to “do their homework”.

In 2012, PNAC has undertaken major activities aimed at strengthening their capacities in performing their organizational functions. These include the (a) conduct of Trainers’ Trainings for STI, HIV and AIDS on the Education Module for RAATs; (b)

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development of a research and evaluation agenda; (c) Communication, Campaign, Advocacy & Social Marketing plan; and (d) the creation of Working Groups on MSM and PWID. But the most major undertaking was the drafting of a Manual of Procedures (MoP) produced in April 2012 as a major attempt to articulate PNAC’s management and governance policies. The provisions in the MoP are based on the provisions of the PNAC Law, RA 8504 and its Implementing Rules and Regulations (IRR), existing resolutions and all issuances confirmed by the Council. The MoP actually translated all policy guidelines into operative guidelines which aim to “provide clarity in PNAC’s organizational directions and strategies to achieve operational efficiency.” It shall be done through the following: (a) harmonizing, synchronizing and systematically aligning the different structures operating independently their processes and systems into the overall mandate of the PNAC; (b) making the MoP as a binding document in relation to HIV prevention and control in the Philippines pursuant to the mandate provided for under the law so that it can operate in an expedient, efficient and timely manner; and (c) providing a mechanism whereby decisions can be immediately made on priority matters that will affect the national HIV response subject to provisions that will safeguard consensus operation.

The drafting of the MoP is an excellent move and is most appreciated by the Council members and the Secretariat staff, though admittedly a long overdue move. The MoP aimed at addressing the issues and gaps raised by the midterm review of AMTP IV in 2007 on the governance, partnership and leadership of PNAC having been identified as the leading cause for the less than optimal performance of PNAC. In the latter part of the first half of the AMTP 5 implementation, a few more major efforts including the MoP have been undertaken to improve management, decision making, and coordination between and among Council members. Just in August 2013, TWCs have been reorganized as approved by the PNAC Plenary Resolution #1 Series 2013 and executed in PNAC Executive Committee Resolution #4 Series 2013, “for a more effective and efficient planning process and implementation of the HIV and AIDS prevention and control in the Philippines.” The ExeCom resolution went even further to define the Terms of Reference and lines of accountability of each of the reorganized committees, which presently includes the (a) Advocacy and Social Marketing; (b) Planning, Partnership & Networking; (c) MultiSectoral Monitoring & Evaluation and (d) Resource Mobilization.

A closer examination and scrutiny of the terms of reference of each of the newly reorganized committees would show that some tasks and functions expected to be assumed by these committees are line functions, while the others, support/staff functions. Line functions are those that are directly contributing to strategic objectives of the plan, while

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support functions are those that provide inputs as support in the performance of the line functions.

Concretely, the functions of monitoring and evaluation, and resource mobilization as defined by ExeCom Resolution #4 Series 2013 are inherently staff/support functions that can be assumed and delivered by fulltime specialists; while functions of advocacy/social marketing and planning, partnership and networking are integral to line functions that are best subsumed and integrated in initiatives that directly contribute to the attainment of the AMTP V strategic objectives. It would then make more sense that line functions are directly reflected in the TWCs outputs that are delivered by appointed Council member agencies and which are ultimately accountable to the ExeCom, while support functions are directly reflected and accounted to the Secretariat, whose personnel are recruited on the basis of competencies and areas of specialization.

Findings from the field still show a general perception of weakness on the part of the Council. Outcomes from the aforementioned initiatives have yet to gestate and bear fruit over time. What is important at this point is that PNAC exercises stronger leadership and tighter controls over its membership. Critical to these is addressing the festering issue of PNAC not having a clear resource base for as the one national coordinating body to the one national response to HIV/AIDS prevention and control in the country.

To this point, resources made available to PNAC from DOH annual budget are for the operations of the Secretariat, a third of which goes to personal services. Individual Council member agencies and organizations are able to access funds from development partners in the undertaking of projects aligned with the provisions of the AMTP 5. While the latter is a welcome endeavor, it still poses the problem of reporting and accountability. The receiving Council member agency tends to be more accountable to the donor than to the Council.

Take the case of the Local Government Academy that received funds from UNDP for a project aimed at strengthening the RAATs through capacity building of DILG regional and municipal/city HIV focal persons, and the other member agencies of the RAATs such as the regional offices of DSWD and DOH. While the capacity building activities were focused and extensive, actual outputs of the projects did not actually translate into gains in mobilizing the RAATs. Not only can work plans for such projects be designed in alignment with the AMTP 5 strategic objectives (strategic #5 specifically), but monitoring the status of its implementation and reporting its actual results to the PNAC Plenary as the ultimate authority can be done, such that lines of coordination and contribution are more clearly established.

With the absence of a clear and sustained resource base & autonomy of PNAC, the Council remains inadequate to oversee the integrated and comprehensive approach to HIV prevention and control in the country and the Secretariat severely limited in its efforts to coordinate the formulation, monitoring and evaluation of plans, programs, policies and strategies to ensure the effective and efficient implementation of the national response.

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While DOH remains as the Chair of the Plenary, PNAC resource base must not remain dependent on it. The Council must urgently find a way of mobilizing resources, from within the Philippine bureaucracy through the member agency budgets and from development partners such that it maintains its autonomy and control in its utilization in accordance to its full mandate as stipulated by law.

Recommendations 1.1

Funds for PNAC should be increased to a level that will ensure core budgets for the operational plans of each of the TWCs. Operational planning shall be prerequisite to fund allocation. PNAC should sub-allocate funds to lead/implementing agency per TWC for the execution of operational plans targeted to move towards achievement of strategic objectives. Working committees should report regularly to the ExeCom; information generated from reports should be consolidated in periodic reports and shared among all Council members and to the general public.

Member agencies/organizations should take the lead in implementing an operational plan in the achievement of the strategic objectives and just reports to the ExeCom through the Secretariat; Secretariat designs and rolls out an M&E plan anchored on the operational plans where information generated from committee reports are consolidated & shared systematically; and PNAC Secretariat performs its core functions to oversee, coordinate & extends technical support when necessary in the execution of the AMTP5 as well as to monitor the response to HIV. 1.2 PNAC structure PNAC governance structures and processes must be made optimally functional as desired and stated in its Manual of Procedures. The Council through the years has been plagued with the problem of inconsistent representation and uneven participation though in the first half of the plan, evidences are manifest that organized efforts to correct these are being exerted. However, memberships remain unnecessarily large thus, maintaining the regular membership of each and every organization or agency must be rationalized and those with clear mandates and positive intents optimally mobilized.

Moreover, insofar as governance is concerned, the Council needs to revisit and reassess how the role of the LACs in the overall national response has been played out in the past. It has been established in the midterm review of the AMTP IV that â&#x20AC;&#x153;The response at the local level is critical for the success of the national program. There is a need for funds, clarity of role and monitoring. Local responses need more support from the national level on how to access funds and plan programs.â&#x20AC;?

Role of the LACs as drivers of the national response at the local level remains unclear as expressed by all stakeholder groups in the field. The MoP does not even mention the LACs in its overall governance system. Findings in this review show and insist that PNAC still needs to facilitate a more systematized and organized decentralized implementation scheme for the national response as proposed in the last midterm review (2007).

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While the LACs are the drivers, the RAATs must be appreciated as the support structure providing technical guidance, easy access to timely and adequate information necessary for managing local responses, and capacity development for local players, among others. Together, the LACs and the RAAT formulates a proactive and strategic plan localizing the national response. All local responses are consolidated in a TWC on Localization, or strategic objective #5. TWCs may later be just called Working Committees as much of their mandates are in direct contribution to the AMTP V strategic objectives, and not just providing technical guidance.

A balance in the responsibility and authority of the Secretariat Director as the chief executive officer (as defined in the Manual of Procedures) must be further strengthened. It falls on the Director the full responsibility of “coordinating the formulation, monitoring and evaluation of plans, programs and strategies to ensure effective and effective implementation of the national HIV and AIDS response” and yet it is not clear what authorities and powers he can exercise in aid of the performance of his duties and responsibilities.

At the beginning of the AMTP 5 implementation, serious attempts were made at arriving at an agreement among Council members to formulate HIV-specific workplans and yet when the process was not completed and the deliverables not achieved, the Secretariat Director, as accountable to the ExeCom, is at a loss on how to proceed. The first draft of 5th AMTP Assessment and its recommendations were presented early December 2013 by a member of Team A (Marie Labajo) to the PNAC Council. Members requested additional and more detailed recommendations on PNAC core functions and the organizational set-up (including memberships and PNAC secretariat structure). To further discuss and exchange on the proposed recommendations in the PNAC organizational structure, the terms of reference for all bodies (Technical Support Committees, Working Groups, Task Forces, Secretariat) and the rationalization for the membership in the Council, a consultative workshop was conducted 16-17 January 2014 with representatives of 9 PNAC member organizations and agencies (LPP, LCP, DOLE, ACHIEVE, PPA, TLF, DepEd, NEDA, DFA). The main conclusions of this workshop were incorporated by Marie Labajo in this section. See also the new organigrams proposed in the Annex 4 as well as the document “Rationalization plan of PNAC Secretariat, PNAC 2014” (ref 21).

Recommendations 1.2: The Secretariat should be brought back under the Council and should operate as such. While the Secretariat provides administrative support to the NASPCP, it must bear in mind that the Council is its ultimate governing body (ref 39). The working Committees should be aligned with the strategic objectives. The strategic objectives should be operationalized & new projects developed with an explicit contribution to HIV control among MSM and IDUs. A greater control of the Council through the ExeCom should be allowed over resources accessing & mobilization, in partnership with development partners; the role of the Secretariat Director as chief executive officer reporting to the ExeCom & Council should be strengthened. The Secretariat Director should have direct control of over support/staff functions, such as Strategic

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Information and Capacity Development. A proposed organizational structure, including PNAC secretariat organigram is presented as Annex 4.

Shift in the appreciation of LGUs from being partners to being co-drivers along with the Council at the local level. Partnership, Networking & Advocacy Committee must be converted to a Localization & Convergence Committee to underscore the primacy of the role of LGUs and community-based CSOs, not just as partners but as co-drivers in the implementation of the national response. As a working committee with a line function, it shall be composed of representatives of LGUs and convened by DILG, shall develop an operational plan specifically designed for LGUs from Categories A&B and shall take full responsibility for LGU/CBO participation in the roll-out of the AMTP5 for the next 3 years.

Moreover, membership in the PNAC should be rationalized on the basis of the following criteria: (1) with existing programs, services and activities that directly contribute to the achievement of the AMTP5; (2) with core mandates that can directly contribute to the performance of the core functions of the Council (oversight, direction-setting and policy making); and (3) with existing constituencies that are targeted by the AMTP5 activities.

Short term actions proposed -bring the PNAC Secretariat back under the Council in the organizational structure of the DOH; -revisit the existing TWCs and assess their alignments with the five strategic objectives (the proposal is that each SO be owned by a TWC where a plan for operationalization be drafted & projects developed with a corresponding lead agency, representative of whom is the Committee Head & Convener); -allow greater control of the Council through the ExeCom over resource accessing & mobilization in partnership with development partners; -strengthen the role of the Secretariat Director as chief executive officer reporting to the Execom & Plenary; - the Secretariat Director should have direct control over support/staff functions (Strategic Information, CapDevt).

1.3 Strengthening PNAC secretariat The Secretariat is presently composed of 12 personnel, 4 are regular DOH personnel and the rest, contractual. Five of these 12 assume administrative support jobs while 5 assume technical jobs, only one of whom takes responsibility for M&E. Efforts to augment the technical staff have been in vain. The incumbent Director has yet to assume a regular position in the DOH Central Office. And with the rollout of the final rationalization plan of the DOH, the Secretariat appears to have increased woes, having only been left with 5 plantilla positions, no one of which is allocated for medical specialists. The five plantilla positions are down to the Director, the Administrative Officer, the Media Production Specialist, the Health 94 | P a g e

Education Promotions Officer and the Project Evaluation Officer. The positions for the medical specialists are presently under appeal at the DOH. Funds made available by the DOH for PNAC are principally for the operations of the Secretariat. It received PhP11M for 2013 and it showed signs of progressive decrease since the time of its inception (started with PhP20M as the law mandated in 1999). It will be receiving however PhP12M for 2014 as approved in the National Expenditure Program of the national government through DOH. Moreover, the Secretariat was faced with very limited human resources窶馬umber and competency-wise-- to perform the tasks and functions assigned them in contribution to the achievement of the strategic objectives of AMTP V. Recommendations 1.3: Staff complement should be augmented to more adequately & effectively perform its tasks and functions, more in competencies than numbers. Core functions of the Secretariat should be limited to capacity development, and strategic communications and information, including monitoring & evaluation of the plan and managing information generated. The responsive and the proactive functions should be clearly delineated. Coordination with LACs should be improved. LACs can be made integral to the TWC working on strategic objective #5, thus mechanisms for cooperation & coordination are instilled.

V.2. Interagency coordination and collaboration strengthened to monitor contributions in the implementation of the AMTP5.

2.1 The National Monitoring and Evaluation System A thorough and rigorous process in establishing and strengthening an M&E system has been undertaken since 2006 through collaboration between PNAC and the United Nations. At the end of AMTP 4 in 2010, an assessment has been made on the 12 component elements of the system, results of which were published and disseminated in a document on the National Monitoring and Evaluation Plan. The M&E system of the national response counts among its major accomplishments the following: creation of an M&E unit in the Secretariat (one expert); activation of an M&E Committee as one of the Technical Working Committee being regularly convened by the Secretariat; enhancement of M&E partnerships and linkages with UN Agencies, the Global Fund and a few technical advisory groups. However, most of the efforts have been in NEC/DOH with the classical monitoring and surveillance activities of HIV as an infectious disease. The weaknesses concern more the national response: HIV prevention as well as Treatment, care and support programs.

The review has likewise identified areas that call for more attention and improvement. M&E structures in the Secretariat and in the ExeCom have not been fully constituted and mobilized, constantly lacking in number of needed personnel (Secretariat) and operating on a need/report-driven basis (e.g. UNGASS Core Team for reporting,

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surveillance technical working group). In the absence of HIV-targeted plans among most member agencies, monitoring progress in contributing to the achievement of the strategic objectives is a misnomer; As such, it is not clear in the terms of reference of designated M&E officers (at least those who have) their M&E functions. Capacity building activities have been design on a project-basis/demand-driven and not based on an overall capacity development plan vis-Ă -vis the M&E plan of the Council; and Dissemination of strategic information from surveillances, research studies, surveys and other studies is not systematically being done (only during national fora and online sites) and their use unclear and not monitored. Those member organizations implementing HIV-related projects (including studies) do not have a system of sharing program reports and analyses. Again, in a seeming performance accelerated plan to catch up with the intended outcomes of the AMTP V, attempts to implement critical courses of action to move the M&E system were only found in the latter part of the first half of the plan implementation.

Improved performance of the M&E system The National MESA study undertaken in 2010 proposed the following actions: -Formalize the creation of the national M&E working group composed of officially designated M&E officers from each PNAC member agency with clearly defined M&E functions; -Conduct series of M&E capacity building activities for the MEWG including the series of M&E planning workshops to transform the draft action plan into a 2011-2016 national M&E plan in line with the AMTP V and with corresponding costed annual M&E workplans; -Define and guide the activities, roles, networking mechanism and resources for monitoring at the national and local levels; -Expand and sustain partnerships on M&E through institutionalization of existing structures; establish and maintain a national M&E database (or sustain the CRIS Pinoy); -Improve routine HIV program monitoring; and establish a system of regular dissemination of strategic information on HIV to ensure utilization by policy makers and program managers.

Three years from the time the comprehensive and elaborate M&E has been designed, the system appears to remain in its nascent stage, its functional use arrested due largely to the absence of clear work plans and budgets both at the level of individual member agencies and the technical working committees.

The M&E Working Group at the national level was composed of officially designated M&E officers from each of the participating member agency and it has rolled out a plan of action where 4 basic capacity building activities/workshops have been conducted participated in by the appointed M&E Officers of each of the member agencies, and representatives from RAATs and strategically identified LGUs (from Categories A & B).

Another one is set before the end of the year primarily to establish standard monitoring and reporting processes and tools in each of the participating member agency. This is a welcome

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move as this can initiate the process of building M&E capacities of appointed HIV focal persons from the contributing member agencies on the basis of a proactive, coordinated national monitoring plan. At the minimum, this series of rigorous capacity building activities can harmonize, at best, synchronize, converge or interface all HIV-related plans at the level of the member agencies. However, first things first---the operational plans at the level of the individual member agencies and the TWCs must be done and the overall M&E anchored on them. M&E however is a support function and therefore must be directly under the control of the Secretariat Director. Should the MEWG be retained, it must be to enhance and support the M&E function of the Secretariat.

The Secretariat can likewise formulate its annual operational plan consolidating all major inputs and actions from the various working committees and in the performance of its tasks and functions.

All informants agree that data are generated by the various implementers but are still not consolidated systematically. Annual accomplishment reports are submitted on a regular basis by Council members and yet it is not clear what use these reports may serve, or that reports with useful information collected are not shared and utilized for further management planning. For members who are undertaking HIV-targeted plans, it is not clear how actual inputs and interventions translate into the actual desired outcomes that indicate their contribution to the achievement of the strategic objectives of AMTP V. Thus, reports generated from Council members and TWCs have not significantly informed and guided the Council in addressing the gaps in the AMTP V implementation.

To date, the Council has yet to make a report to the Office of the President, advising it of the most critical developments in the spread of the infection and calling for urgent and critical actions to move closer to the desired result of getting to zero incidence.

Moreover, the monitoring plan that follows from the results framework can still be further developed by indicating the baselines, the targets and the performance indicators for each of the 5 strategic objectives, with clearly defined methodologies for generating the necessary data, the frequency and the responsible agencies or organization for the data collection. Only when these monitoring plans are clearly established, can inter-agency coordination and collaboration become urgent and relevant in assessing the progress made in the implementation of the national response.

Recommendations 2.1: Enhance the existing M&E system with a clear monitoring plan anchored on the results framework and statement of strategic objectives of the national response, with clear baselines, targets and performance indicators, methodologies for generating the necessary information, frequency and the responsible agency for the data collection. Revisit the overall M&E system and monitoring plan vis-Ă -vis the operational plans that shall be developed by the Working Committees and the Secretariat. LGUs and LACs must be supported, coordinated, monitored and strengthened.

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VI.

Strengthening Capacities of Local Governments and Communities

Introduction The AIDS Prevention and Control Act (R.A. 8504) mandates the Local Government Units (LGUs) to develop and implement their own HIV prevention programs. Since the Philippine health system had been decentralized, LGUs were responsible for health services.

The 4th AIDS Medium Term Plan assessment conducted in 2008 found the scope of the plan to be not defined or detailed enough for implementation in the field, particularly for local government units, and that, although the local response is a key element of the country’s program and the LGUs are the mainstay of the program, they have been barely mentioned in the plan. The assessment also noted that the response at the local level is critical for the success of the national program and recommended the facilitation of decentralization. Specifically, it stressed the need for national level support to local responses in terms of access to funds and capacity development in planning and budgeting75.

Thus, the key strategy under the Strategic Objective 5 of the 5th AIDS Medium Term Plan aims for good governance and accountability and focuses on strengthening the capacity of partners in the national response to include the local governments, the private sector and communities at-risk for, vulnerable to and living with HIV and AIDS.

VI. 1 Strengthening Local Governments for Responses 1. 1 Regional AIDS Assistance Teams (RAATs) The RAAT was created by virtue of a PNAC Resolution in 2007 to facilitate the scaling up of local AIDS response.

The RAAT is composed of focal persons from the Department of Interior and Local Government, Department of Health and Department of Social Welfare and Development; considered to serve as a bridge between PNAC and the LGU local HIV/AIDS councils (coordinating bodies) or LACS; provide technical assistance; support capacity building activities; coordinate between LGUs and community-based organizations; disseminate HIVrelated information; do advocacy among the different regional stakeholders; and monitor and evaluate regional data and situation to enable LGUs to tailor their HIV and AIDS response.

The UNDP “Leadership for Effective and Sustained Responses to HIV and AIDS” project (2009-2011), in collaboration with the DILG through the Local Government Academy (LGA), supported the strengthening of the RAATs. Useful tool kits were developed to prepare the RAATs and other local government leaders to adopt pro-active roles within their regions and cities/municipalities: (a) “Localizing the HIV and AIDS Response: Local Government Guide for Practical Action” to serve as a guide in establishing a local AIDS response for local government officials, and (b) “Policy Review (Case Studies): The AIDS 75

Mid-Term Review Report- Fourth ADS Medium Term Plan 2005-2010, 2008

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Prevention and Control Ordinances of Quezon City and Pasay City” to serve as models and encourage LGU efforts to support initiatives .

The evaluation conducted for the UNDP program in 2011 reported that RAATs were established in nine (9) out of the total seventeen (17) regions throughout the country76.

RAATs were active in eight, (8) regions: I, II, IV-A, VI, VII, VIII, X, and XI. Accordingly, RAATs were not successfully established in the eight (8) remaining regions because of the lack of consistent members to complete the series of training sessions.

The review found the activities associated with RAATs to be short-time focus. Based on interviews of RAAT members and reports from the website, activities have focused mainly on mobilizing HIV/AIDS awareness and on coordinating HIV-related events in the community. For example, the RAAT in Region II implemented orientation/workshops to promote public awareness on HIV/AIDS for the youth groups (Sangguniang Kabataan) to become advocates.

From the survey of HIV Stakeholders conducted in October 2013, respondents have expressed that “the RAATs are not felt or known in the cities/LGUs.” Similarly, among the seven (7) LGU cities visited (Quezon, Angeles, Paranaque, Kalookan, Cagayan De Oro, Baguio and Puerto Princesa), informants from six (6) LGUs claimed they are not aware or have never heard about the RAATs. Only one (1) city, Cagayan de Oro, has positively mentioned that they know the RAAT to be active in implementing orientation on HIV/AIDS in government offices.

The review was unable to find evidence that the RAATs were involved in strengthening the LACS in the corresponding regions. None of the LGU city health officials and SHC physicians who were consulted received technical assistance from the RAATs. Financial constraints related to unclear coordination with LGUs appear to be hindering RAATs mobility and effectiveness. In the LGU where the RAAT was active, attendance to LAC meetings was possible only when there was somebody from the corresponding LGU to sponsor travel.

While the RAAT is conceived as an interagency collaborative work at the local level, no evidence would show that is happening. The 3 member agencies continue to undertake their own agency-specific HIV-focused activities and were not found to be working as a collective. Local players are aware of its existence but their presence is not felt. Relations with LACs have been more bilateral rather than an interagency body dealing with the LGUs in the formulation and implementation of their local responses.

Moreover, it even appears that the strength of LACs is not necessarily contingent to the strength of RAATs. In some strategic priority areas, LACs perform optimally without any form of assistance received from their RAAT counterpart.

Recommendation 1.1 RAATs to be effective in the response should refocus what they are doing. Since they are strong in advocacy, they can be developed into champions to support LGU Promoting Leadership and Mitigating the Negative Impacts of HIV and AIDS on Human Development. An outcome evaluation of UNDP’s HIV Programme in the Philippines 2009-2011 76

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planning and budgeting processes as well as to advocate to LGUs to implement priority HIV programs.

1.2. Local HIV/AIDS Council The Local HIV/AIDS Council (LAC) is the body mandated by law (R.A. 8504) to assist their respective Sanggunian in setting the direction of HIV and AIDS-related programs and activities. The Council institutionalizes LGU and NGO partnership at the local level by putting in place ordinances, policy and resources to HIV and AIDS activities.

LGUS have formed LACS either through local ordinances or executive orders which are multisectoral in composition. According to the 2013 LAC Inventory of the DILG, from eight (8) LACS created in 2002, the number has increased substantially by 2013 to 642 (37%) out of the 1,713 total LGUs in the country; 109 (78%) out of 140 cities, 506 (34%) out of 1,494 municipalities and 27 (34%) out of 79 provinces. The review was unable to validate the DILG data and to determine the status of the LACS functionality as there was no data monitoring at PNAC. Through local ordinances, some local government initiatives and efforts to support LACS include the following: a) adoption of local ordinances mandating 100% condom use policies in registered entertainment establishments; b) local ordinances to improve the quality and expand the operation of social hygiene clinics; c) assumption of the operating costs of surveillance activities; d) community outreach and preventive education activities of several nongovernmental organizations (NGOs); and, e) non-hiring of minors77.

The DILG Memorandum Circular No.29, s13, enjoining cities to adopt strategies including the creation of LACS, could provide encouragement to LGUs to accelerate local response.

LAC Functionality LGUs define â&#x20AC;&#x153;functioningâ&#x20AC;? as the presence of LAC workplan, LAC budget, and when the members are meeting regularly. LGUs, however, differ in how they define the frequency and regularity of meetings. Members (individuals and organizational representatives) usually attend monthly regular meetings. According to informants this appears to have been working well in most cities when there was external donor support under the GFATM Grants on HIV. Currently, some LACs meet only when needed. For example, the LAC in Paranaque has met only twice in the last two years, yet, they consider their LAC to be functioning.

In LGUs where LACS are operational, most of the initiatives are focused on implementing the usual HIV services and AIDS awareness events rather than on developing new policy initiatives. For example, among the seventeen (17) cities classified as highest priority (Category A) for HIV prevention, majority or twelve (12) LGUs implement STI/HIV/AIDS services at SHC targeting mainly the RFSWs. Only five (5) cities (Quezon, Makati, Cebu, Davao, Angeles) have local ordinances to support LACS that include local government efforts to improve the quality and expand the operation of the social hygiene clinics and are hiring peer educators (PE) using local funding to access MARPs with education and HCT.

Best practices in HIV and AIDS education prevention. AIDS Surveillance and Education Project/PATH Report Best Practice 77

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Recommendations 1.2: PNAC should establish a system for monitoring the LACS to guide TA strengthening efforts.

LACS need to be strengthened and given exposure to innovative prevention efforts to develop more effective programs. Some LACS are very effective and PNAC should facilitate sharing and cross training through technical exchanges or inter-LGU sharing, where LGUs with more experience can mentor the others.

1.3. LGU Ownership of HIV Response Of the 70 priority areas identified for HIV intervention, 22 cities/municipalities were classified highest priority or Category A - all the 17 cities/municipality in the national capital region (NCR), plus the cities of Angeles, Davao and three (3) cities located in the Metro Cebu area- Cebu, Mandaue and Danao78.

The 2013 Rapid Situational Assessment conducted by PNAC provided data on the HIV status of the Category A cities79. Data analysis focused on existing institutional mechanisms that would allow LGUs to sustain HIV/AIDS prevention including the presence of LAC, developed workplan and LGU budget allocation specific for HIV.

Status of LACs in Category A, 22 Cities

With LAC Without LAC

Number

Presence LAC Work plan

w/ HIV Budget Allocation (GAD, City, CIPH)

w/o HIV Budget

17

9

11

6

5

0

1

4

 17/22 (77%) have LACs  9/17 (53%) have LAC Work plan  11/17 (65%) have specific HIV budget allocation (Source: PNAC Rapid Assessment, 2013)

The review found the evolution of development for decentralization for the local response to be slow but moving.

Data from the 22 high priority cities (Figure) showed that seventeen (17) out of the 22 highpriority cities (77%) have LACs; of which, 9/17 (53%) have LAC workplan; and 11/17 (65%) have budgets specific for HIV/AIDS. LGU cities are allocating budgets for HIV/AIDS using local funding. However, political support and budgets have been uneven and HIV responses were not always sustained. For example, (A) Quezon City has been able to mobilize local funds for HIV/AIDS- relatively more substantial amounts in budget allocations for STI/HIV/AIDS that include P3M from city fund, another 10% from GAD, P5.6M from the national treasury thru fund transfer via DOH for the construction of a new SHC, another P5.6M from the national treasury thru fund transfer via 78 79

Philippine Priority Areas for HIV Intervention (PAHI) NEC Memo March 5, 2012 ASEAN Getting to Zero, Results of the Rapid Assessment Study. PNAC and CHD-NCR, 2013

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DSWD for establishing a clinic for MSM; (B) eight other cities â&#x20AC;&#x201C; have budget allocations for HIV/AIDS programs ranging from P50K to P5M: Mandaluyong, Pasig, Navotas, Makati, Paranaque, Mandaue, Davao, Angeles; (C) there are cities that continue to access support from donors/external resources i.e. GFATM-TFM; and (D) some LGUs that previously received support from donors/external resources were not continued.

LGUs need planning and advocacy skills to accelerate decentralization of the HIV/AIDS response. LGU cities that were able to access funding and allocate budgets for HIV received technical assistance (TA) on strategic and financial planning. Examples of TA include: 1) UNDP/UNAIDS through NEDA on capacity building for development of City Investment Plan for AIDS (CIPA) for the following cities: Quezon, Pasay, Caloocan, Cebu and Davao) and identification of financing sources for CIPA (assisting LGU in understanding and accessing Local Poverty Reduction Program- Bottoms up Budgeting GAD funds, etc). 2) USAID through the HealthGov project (2006-2011) provided TA on strategic and financial planning for 11 selected cities, support for inter-LGU collaboration planning in Metro Cebu, and support for development of financing mechanism for an MSM PE program in Davao City.

The share of LGU investment for HIV/AIDS remains relatively small. Data from the NASA for 2012 indicate local government allocations to be only 19% of total AIDS spending.

The review found PNAC to have been unable to provide enough facilitation or monitoring for decentralization. The review did not find evidence that the RAATs played a significant role in the scaling up of local ownership of the response.

Recommendations 1.3: PNAC and DOH should strengthen LGU capacity to develop City Investment Plans for AIDS and to identify financing sources for HIV/AIDS. Investment planning for HIV should be expanded in all priority areas.

VI. 2 Strengthening Communities for HIV and AIDS Responses 2.1. Partnerships - Civil Society Organizations (CSOs)/Communities At-Risk Strengthened The role of civil society in the national response to HIV and AIDS has been recognized in the Philippines. CSOs assist national agencies and LGUs to implement sector-specific responses in various geographic sites in the country and contribute to behavior change needed for HIV prevention as well as support PLHIV. According to the 2012 Global AIDS Response Progress Report (GARPR), there were about fifty (50) CSOs contributing to the response. CSOs have been rated highly for their involvement in planning and budgeting for the National Strategic Plan on HIV. PLHIV CSOs, including the Positive Action Foundation, Inc (PAFPI, Inc), and the Pinoy Plus Association, Inc. (PPA), were seen as staffed by individuals with skills in program and financial management as well as in strategic planning. Currently CSOs representing six (6) sectors namely: PWID, MSM, sex workers, OFW, Labor and PLHIV participate in governance and in fact are represented in the PNAC. PLHIV is also a member of the Country Coordinating Mechanism of the GFATM and are usually members of LACS. (DILG Memo Circular) PLHIV participation was well demonstrated in the treatment model to implement anti-retroviral treatment (ART) with hospital-based treatment facilities under the GF-R6 on

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HIV Grant as well as under the current GFATM-TFM. The PAFPI’s outreach activities promoted enrollment of PLHIV and their families to receive basic and psychological support and counseling on adherence to ART. PAFPI trained the HIV/AIDS core teams HACTs on palliative and home-based care (HBC) in project sites. PLHIV partner NGOs include: Pinoy Plus Association and Babae Plus (Metro Manila); Cebu Plus (Cebu City); United Western Visayas, Inc. (Iloilo City); Crossbred, Inc (Bacolod City); and Mindanao AIDS Advocates (Davao City). Training of HACTs has resulted in partnership and establishment of mentoring initiatives with the partner NGOs. The strong referral network established between HACTs/treatment hubs and the PLHIV/MSM support groups has contributed to increasing enrollment to ART. This indicates the PLHIV and MSM groups were credible among their peers and have the potential to become effective counselors for HIV testing. PLHIV and MSM participation and involvement to implement HCT should be explored.

Participation in Governance The 5th AMTP aimed to enable engagements of CSOs in governance of HIV/AIDS. There are CSOs that have integrated HIV in their core work and are assisting in the management of HIV and AIDS. Examples of LGU partnerships with the civil society groups considered to have the potential to become models of good practice include the following: a) League of Angeles City Entertainers and Managers (LACEM) – has its own office in the Social Hygiene Clinic building. LACEM is an organization composed of ‘mamasans’ (pimps) and entertainment establishment managers that work closely with city health officials. LACEM serves to improve compliance and enforcement of the labor code that prohibits employment of minors in entertainment establishments by helping to verify girls’ true identity and legal age. The SHC regularly conducts seminars to encourage RFSWs to adopt STI/HIV prevention practices including the importance of knowing their HIV status. The” mamasans” also receive orientation to help reinforce risk prevention behavior. In 2013, the SHC reported that all RFSWs have submitted for voluntary HIV testing during the annual registration. LACEM also manages the funds of RFSWs to provide for health and welfare services of RFSWs. The partnership has been working well and has become sustainable. b) Quezon City Pride Council- the Quezon City government formed the Quezon City Pride Council in March 2013 to oversee the integration of all city programs and projects for the lesbian, gay, bisexual and transgender (LGBT) constituents, to combat stigma and discrimination within the city. Task Force Pride, a network of various LGBT and human rights organizations hopes to see other cities in Metro Manila create their own programs to end discrimination based on gender and sexual orientation. Thus far, no cases of stigma and discrimination have been reported. c) BALUTI – (Batang Laging Umiiwas sa Tiyak na Impeksyon) - a youth-led organization composed of volunteer peer educators who once belonged to the most at-risk groups, multiple sexual partners, and IDUs. The peer educators work closely with the Paranaque SH C to address the problems of adolescents who are at early risk for early sexual debut, teen-age pregnancy, risky sexual practices, STI, HIV and AIDS. Available data showed BALUTI reached around 15,000 adolescents with preventive education, counseling and referral for HIV testing with support from the Paranaque SHC and MTV Staying Alive Foundation in 2009. d) Barangay Gender and Development (GAD) HIV Focal Leaders- the Barangay (village) leaders are other important stakeholders for the local response. Under the GAD Program of the Barangay, the Quezon City Health Office trained focal persons/educators assigned in priority areas (red-light districts) to implement HIV 103 | P a g e

and AIDS education in the community. GAD program focuses on violence against women and their children and other gender-related issues concerning men. e) Klinika Bernardo – LGU-owned and managed MSM clinic in Quezon City has for its theme “Male Wellness”. It became operational since December 2012 and is operating from 3 PM-11PM from Monday-Friday. Clinic staff is composed of: 1 doctor, 1 medical technologist, 2 nurses, 5 peer educators and 1 Barangay health worker. Every 2nd and 4th Sundays of the month, the NGO called Take the Test manages the clinic. LGU partnership with the MSM community is being strengthened by GFATM thru NGOs (AIDS Society of the Philippines, Take the Test) and thru the USAID/FHI Reaching Out to Most at-risk Population (ROMP) project support for development of modeling interventions targeting MARPs/MSMs. Klinika Bernardo also works in partnership with NGOs, (AIDS Society of the Philippines, Take the Test) to implement outreach mobile HIV testing. Clients came from referral, through the internet posts, word of mouth and the advertisement in the tarpaulin. The clinic, at the time of visit attends to about 300 MSM cases per month (average of 10 per day) and accordingly, the number has been increasing. Clients were approximately 40% from Quezon City and 60% from the rest of the country.

PNAC provided coordination and support to CSO/communities at-risk through its six (6) NGO members involved in HIV prevention, treatment, care and support including one organization of persons living with HIV and AIDS: Pinoy Plus Association (PLHIV), PNGOC (PWOD), TLF-Share (MSM), TUCP (Labor) ACHIEVE, Inc. (OFW) and Lunduyan (Children) Recommendations 2.1 PNAC should evaluate LGU partnerships with the civil society groups to identify potential models for replication.

More MSM and PWID community organizations should be engaged and strengthened to be able to increase coverage of the 2 populations at risk.

Planning for sustainability of LGU/CSO partnerships should be supported. PNAC should engage local stakeholders in sustainability planning.

2.2 Enhancing Network of the National HIV and AIDS Response 2.2a Public-Private Responses The PNAC had the foresight to recognize the potential impacts of HIV early and initiated a comprehensive and progressive workplace HIV policy and program to reduce susceptibility of labor sector workers to HIV and to refer for treatment those that need it.

Following the Department of Labor and Employment (DOLE) issuance of the AIDS Policy in the Workplace in 2000, implementation of a number of initiatives has been undertaken including advocacy, networking, information dissemination and training. The Occupational Safety and Health Center (OSHC) integrated STI/HIV/AIDS in on-going training of the Center.

Training of trainers (TOTs) were carried out and monitoring and evaluation systems have been integrated into the training program. Training courses were implemented in the regions. For OFWs, lecture on HIV/AIDS are conducted by an NGO. DOLE developed and distributed information, education and communication (IEC) materials including: “A Primer on HIV and AIDS for Workers and Employers” with information included on the DOLE Department Order No. 102-10 and FAQs on R.A. 8504. The primer is a useful reference for employers and workers.

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Consequent to the issuance of the DOLE AIDS Policy in the Workplace, policy and support interventions have emerged to assist in mainstreaming HIV/AIDS: The Trade Union Congress of the Philippines (TUCP) launched the Kilusan sa Jolibee nationwide and AIDS concerns were included in the bargaining agreements; Civil Service Commission (CSC), DILG, DepEd, DSWD circulars were issued to increase HIV/AIDS awareness in the workplace covering their sectors; and, Quezon City LGU passed an ordinance requiring workplace HIV policy prior to issuance of business permits.

According to the 2012 GARPR, only 5% of establishments comply with HIV in the workplace policy. Workplace activities have yet a very limited coverage as the target is to serve the 31 million workforce or the estimated 820,000 establishments in the formal sector and therefore, should be accelerated.

2.2b Partnership with the Business Sector The Philippine Business Sector Response for HIV (PBSR) supports the PNAC to implement the HIV Policy in the Workplace, disseminate HIV/AIDS information, and combat stigma and discrimination.

The network was launched in 2009 in collaboration with the PNAC, PBSP (Philippine Business for Social Progress), ILO, UNAIDS, UNDP, Pilipinas Shell Foundation, and The Love Yourself (TLY) Foundation. PBSR have engaged and trained 38 partner companies including: Business Process Association, Philippine Management Association of the Philippines, EON Inc, HSBC, Standard Chartered Bank and Lorenzo Shipping, among others.

PBSR supports partner companies on capacity building for TOTs and PE training and the development of workplace policies in companies; implements â&#x20AC;&#x153;90 minute workshopsâ&#x20AC;? with interactive participation of employees in partnership with the Love Yourself NGO; engages partners in community commitment e.g., partners with the Makati LGU and TLY Foundation to implement voluntary HIV testing; enhanced HIV 101 by developing an audio-visual presentation (AVP) that is being shared with other companies and NGOs; partners with faithbased NGO called, St. Camillus, to implement HIV 101 targeting college and high school students.

PNAC has been active in providing support to PBSR initiatives, including the conduct of training of trainers; accreditation of trainers of TLY NGO; participation in dialogues and consultations; and provision of technical comments on HIV testing.

2.2c Partnership with Faith-Based Organizations (FBOs) In the Philippine context, it is critical to forge strong partnerships with faith-based organizations .Though not officially a member of the PNAC; FBOs have undertaken remarkable initiatives including the development of a Training and Resource Manual for Catholic Pastoral Workers. Many other activities related to HIV awareness and care and support have been implemented80.

The FBOs are looking at working together to unify efforts to address HIV. FBOs with HIV programs have gathered together recently in 2013 to end stigma and discrimination associated with HIV and AIDS. FBOs include: the Cosmopolitan Church, the World Council of Churches (WCC), the National Council of Churches in the Philippines (NCCP), the National 80

5th AIDS Medium Term Plan

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United Church of Christ in the Philippines (NUCCP), and the International Religious Leaders Living with and Personally Affected by HIV/AIDS (INERELA).

The Philippine Catholic HIV and AIDS Network (Phil-CHAN) has members composed of Catholic congregations and/or organizations. The Ministers of the infirm of St. Camillus is one of nine (9) founding members. The others are: Catholic Bishop Conference of the Philippines (CBCP)- National Secretariat for Social Action (NASSA)-Caritas Foundation, CBCP â&#x20AC;&#x201C; Episcopal Commission for the Pastoral Care of Migrants and Itinerant people (ECMI), Sister Ministers of the Sick St. Camillus, Daughters of Charity, Brothers of Mercy, Missionary Sisters Servants of the Holy Spirit, Manila Chaplaincy Ministry of Health Care and Apostleship of the Sea-Manila. In collaboration with PNAC and UNAIDS, the Network was launched in 2010 with 19 Catholic organizations, and has grown to 44 in 2012.

Under the PNACâ&#x20AC;&#x2122;s Going to Zero and Stigma fuels the spread of HIV themes, the PhilCHAN implements training activities related to prevention, TCS, advocacy and networking.

Some of the accomplishments of the network include: at least 80 bishops were given orientation on HIV and AIDS in 2011 and are now helping to raise awareness and address stigma and discrimination; trained pastoral service providers to provide HIV/AIDS counseling, pastoral care, home-based care and palliative care; and, mainstreamed HIV in parish activities, i.e. orientation of Barangay health workers in the rural health units. PhilCHAN has developed a TCS referral system for the network members and promoted partnership and collaboration with Governments and CSOs. The network participated in the 5th AMTP Strategy planning.

Recommendations 2.2 Evaluation should be conducted to ascertain coverage and effectiveness of the AIDS policy in the workplace interventions, especially in companies and networks with wide labor force.

PNAC should increase facilitation to strengthen partnerships with CSO networks, especially with MSM groups, to increase coverage.

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Annex 1. List of Team members Team A Name

Organization

1.

MICHEL CARAEL

2.

Contact Number

Email Address

CORAZON R. MANALOTO

CONSULTANT TEAM LEADER CONSULTANT

09189157715

3.

MARIE LABAJO

CONSULTANT

09177965274

4.

JOSELITO FELICIANO

PNAC SECRETARIAT

09164202019

5.

KHRISTINE FULLANTE

PNAC SECRETARIAT

09179025591

6.

MALOU L. QUINTOS

UNAIDS

09175786750

coramanaloto@yahoo.c om.ph marie_cribs@yahoo.co m jojorfeliciano@gmail.co m khristine.fullante@pnac .org.ph quintosm@unaids.org

7.

ZIMMBODILION MOSENDE ADRIAN ALEJANDRO

UNAIDS

09178626675

mosendez@unaids.org

PNAC SECRETARIAT

09276529375

KENNETH JIM JOSEPH M. JIMENO 10. KAREN MAE MONTESA

PNAC SECRETARIAT

09163066611

PNAC SECRETARIAT

09064511433

11. MARIA NORIE M. SANTOS

PNAC SECRETARIAT

09178820180

adez_alejandro@yahoo. com kennethjimeno@mail.co m karenmae.montesa@ya hoo.com mnms@yahoo.com

8.

9.

caraelm@yahoo.fr

Team B External review team members (1)

(2)

Daniel Tarantola (Team Leader) International and Global Health Consultant 15, Chemin de Valavran 01210 Ferney-Voltaire France Tel: (33) 9 6320 8723 djmtarantola@gmail.com Kathleen Casey Public Health Consultant Clinical and Health Psychologist Bangkok, Thailand Tel: (662) 651 4713 kb.casey@hotmail.com

(3)

Gerald (Jerry) Owen Jacobson Calle 59 N4-56 Apt. 701 Bogota, Colombia Tel: (57) 310 782 3478 jerryjacobson@gmail.com

(4)

Shinsuke Miyano Medical Officer Bureau of International Cooperation National Center for Global Health and Medicine (NCGM) 1-21-1 Toyama, Shinjukuku, Tokyo, 162-8655, Japan Tel: (81) 3 3202 7181 ext.

5152 or 272 s-miyano@it.ncgm.go.jp

(5)

Ethel Dano Independent Consultant 25-C Gorordo Avenue Cebu City, Philippines Tel: (63 32) 233 2806 Mobile: (63) 933 339 1732 (63) 915 875 7509 ethel_dan@yahoo.com

WHO Secretariat (6)

Ying-Ru Lo Team Leader, HIV/AIDS and STI Unit WHO Regional Office for the Western Pacific P.O. Box 2932, 1000 Manila, Philippines Tel: (632) 528 9714 loy@wpro.who.int

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(7)

Pengfei Zhao Technical Officer (Prevention) HIV/AIDS and STI Unit WHO Regional Office for the Western Pacific P.O. Box 2932, 1000 Manila, Philippines Tel.: (632) 528 9718 (13) zhaop@wpro.who.int

(8)

Nerissa Dominguez National Professional Officer HIV/AIDS and STI Unit WHO office, Ground Floor, Building 3, DOH Manila, Philippines Tel.: (632) 528 9766; (14) 3106370 dominguezm@wpro.who.in t

(9)

Teodora Wi Medical Officer (STI) Human Reproduction 1211 Geneva 27 Switzerland Tel: (41 22) 791 4575 E-mail: wit@who.int

(10) Kevin O'Reilly Scientist Key Populations and Innovative Prevention, WHO 1211 Geneva 27 Switzerland Tel: (41 22) 791 4507 E-mail: oreillyk@who.int (11) Riku Elovainio Technical Officer Health Financing Policy WHO, 1211 Geneva 27 Switzerland Tel: (41 22) 791 2028 elovainior@who.int Local secretariat team members (12) Jose Gerard Belimac Programme Manager

(15)

(16)

(17)

National AIDS and STI (18) Teddy Mondres Prevention and Control Research Assistant Program DEBS, UPM-CPH DOH Manila Mobile: (63) 917 5216709 Tel: (632) 4950149; 651 teddy.mondres@gmail.com 7800 ext. 2350 (19) Helen Paaño naspcp@yahoo.com; Project Associate III jgbbelimac@co.doh.gov.ph NASPCP-IDO-NCDPC Noel Palaypayon DOH Manila Supervising Health Tel: (632) 4950149 Programme Officer hpaano@gmail.com National Epidemiology (20) Mary Joy Morin Cener Project Associate III DOH Manila NASPCP-IDO-NCDPC Tel: (632) 495 0513; 651 DOH Manila 7800 ext. 2952 Tel: (632) 4950149 Noel_1226@yahoo.com Mobile: (63) 917 633 1025 Ofelia Saniel E-mail: Local Consultant Team jhoie_lamb@yahoo.com Leader (21) Hilario Umali Department of Project Associate III Epidemiology and NASPCP-IDO-NCDPC Biostatistics (DEBS) DOH Manila College of Public Health Tel: (632) 4950149 (CPH) Mobile: (63) 927 489 3549 University of the Philippines E-mail: Manila (UPM) hilarioumali@gmail.com Mobile: (63) 922 863 3542 opsaniel@gmail.com (22) Krizelle Ann Ronquillo Project Associate III Aura Corpuz National Epidemiology Local Consultant – Team Center Member DOH Manila DEBS, UPM-CPH Tel: (632) 495 0513 Mobile: (63) 917 999 8864 Mobile: (63) 922 818 3704 aura.corpuz@gmail.com kgronquillo@gmail.com Maria Sonia Salamat (23) Clarissa Ignacio Local Consultant – Team Project Assistant III Member National Epidemiology DEBS, UPM-CPH Center Mobile: (63) 999 888 8819 DOH Manila msssalamat@post.upm.edu Tel: (632) 9135380 .ph Ignacio.clarissa@gmail.com Juan Paolo Gasgonia (24) Geoffrey Garcia Research Assistant Project Assistant III DEBS, UPM-CPH National Epidemiology Mobile: (63) 917 897 6929 Center paolo.gasgonia@gmail.com DOH Manila Tel: (632) 495 0513

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geoffgarcia.hiv.nec@gmail.c om (25) Marlene Bermejo HIV Surveillance Database Supervisor National Epidemiology Center DOH Manila Tel: (632) 9135380 marlene.rillera@gmail.com (26) Jessica Raphaela Mirano Project Associate III National Epidemiology Center Department of Health Tel.: No: (632) 495 0513 Mobile: (63) 917 568 5886 Jessica.mirano@gmail.com (27) Jonathan Neil Erasmo Medical Specialist II STI HIV Coordinator Center for Health Development for Central Visayas DOH Osmena Boulevard, Sambag II, Cebu City Tel: (63 32) 2544387 jneilverasmo@yahoo.com (28) Charity Perea Nurse-STI/HIV/AIDS Program Coordinator Abito Street, Mandurriao Iloilo City Tel.: 033-321-02-04 (29) Geofford Montejo Jr. Nurse-STI/HIV/AIDS Program Coordinator J. P. Laurel Ave, Bajada, Davao City Tel.: No: (63 -82) 305-1097 ford_bodik@yahoo.com (30) Raquel Montejo Medical Specialist Central Health District â&#x20AC;&#x201C; Davao Region J.P. Laurel Avenue, Bajada Davao City Tel: (63-082) 305 1097

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Annex 2. Opinion survey about PNAC among key stakeholders The questionnaire was developed by the team and the online survey carried out between October 4 and 16, 2013. Kenneth Jim Joseph conducted most of the survey follow up and analysis. Several databases of respondents involved in the HIV national response were merged. A total of 622 respondentâ&#x20AC;&#x2122;s e-mails addresses was the sample and contacted by e-mail, among which 76 respondents filled out the online questionnaire. This response rate of 12.2 % is typical of this type of online survey (usually about 10%).

The majority of respondents belong to the public sector (40%) followed by community and civil society organizations (27%); research and academia represent 5%, bi-and multilateral partners (5%), private sector (4%) and others from a variety of occupations. Ninety four percent of respondents are engaged in the HIV national response. Sixty three percent belong to an organization that participated in the design and/or the implementation of AMTP5. Eighty three percent belong to organizations that work for more than 5 years on the HIV response. 73% have worked themselves for more 4 years on HIV. Eighty eight percent of the organizations are aligned with the strategies of the AMTP5.

The opinions were quite mixed about the general progress made in the national response. Among the qualitative responses of the respondents, there was the opinion that the AMTP5 needs stronger visibility, that the multi sectoral engagement was not strong enough, that PNAC needs to be better capacitated in terms of budget and authority for fulfilling its role.

Philippine National AIDS Council (PNAC) 1. How satisfied are you with the progress made in the implementation of the 5th AMTP? 39% of respondents were satisfied and 30% were unsatisfied or very unsatisfied.

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2. To what extent do you think that the 5 objectives of AMTP5 have been addressed in the last 3 years?

The majority of respondents thought that all objectives were either partially or not addressed. There is an opinion that HIV prevention was particularly not well addressed.

3. How satisfied are you the way the national response is doing in the following aspects?

Low degree of satisfaction with AMTP5 implementation or financing. Targeting the right groups, implementation and using the right strategies, got the best opinions, with 50% or more of satisfied or very satisfied.

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4. In your opinion, what are the 3 major factors, among those listed below, that are obstacles to an effective response to HIV? Stigma and discrimination, policies and laws, the lack of community centered design and delivery of programs, were the most common responses, followed by cultural values.

Cultural values Poverty Policies and laws Stigma and discrimination Programs coverage Poor program implementation Low capacity Lack of community centered design and delivery Research and innovation Local response to change risk environment Other

10% 4% 14% 17% 9% 9% 4% 14% 7% 9% 4%

5. How satisfied are you with PNAC in terms ofâ&#x20AC;Ś A majority of respondents were satisfied or very satisfied

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6. In your opinion, how much influence has had PNAC on the way other organizations work on HIV? 43 % responded not influential or partially influential, particularly on the religious sector, other government sectors and on the policy level.

PNAC Secretariat 7. How effectively does the PNAC secretariat coordinate with partners?

42% partially or not effective versus 28% effective or very effective

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8. How appropriate is the Secretariat in terms of…

In general, the majority of the responses felt that skills, management structure and to a lesser extent, staffing were appropriate or very appropriate. High levels of “do not know” among the respondents.

9. How would you describe the coordination of programs between PNAC and the following organizations?

In general, there were good opinions of coordination with DOH, Global Fund and UN partners. Many “do not know” responses for partners such as ADB and USAID. The lack of coordination of PNAC with LGYs and RAATs was pointed out by a majority of opinions.

DOH GF/CCM UN ADB USAID. LGUs RAATS

Do not know

Good or excellent

Poor or very poor

14% 22% 29% 53% 45% 25% 33%

64% 57% 58% 32% 44% 35% 30%

22% 21% 23% 15% 11% 40% 37%

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10. Do you agree that the approach of PNAC for involving civil society partners and building their capacity has been very effective?

70% agree or strongly agree with this statement.

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ANNEX 3 Documents reviewed and data sources Reports, tools and guidelines 1. Audit Report No: TGF-OIG-09-008 2010 Audit Report on Global Fund Grants to the Philippines.

2. Grant performance report, Philippines PHL-607-G08-H, Oct 2012 3. 2011 IHBSS Report, impact and outcome indicators, 15 June 2011.

4. 2009 IHBSS, fact sheets by site 5. Health Sector Models to increase access to HIV Counseling and Testing (HCT) among MSM in the Philippines. NEC-DOH and WHO WPRO, Oct 2012 6. UNDP/USAID/UNAIDS/AIDS Projects Management Group. Towards universal access: Examples of municipal programming for MSM and transgender people in six Asian cities. UNDP, 2011.

7. Health Action Information Network/UNDP. Assessing the risks and vulnerabilities of Filipino MSM and Transgender (TG) people in three cities. HAIN, 2012.

8. Tayag E.A. Trending now, HIV in the Philippines, PowerPoint presentation, NEC-DOH, 2012.

9. UNDP, WHO, UNAIDS, UNESCO, APCOM, USAID, ASEAN. Developing a comprehensive package of services to reduce HIV among MSM and Transgender populations in Asia and the Pacific. Regional Consensus Meeting 29 June-1 July 2009, Bangkok, Thailand, UNDP 2009.

10. NAC, UNDP, AusAid. Assessment of Peer Education Approaches for Sex Workers and People Who Inject Drugs as an Intervention Strategy for STI, HIV and AIDS prevention, College of Public Health, University of the Philippines Manila, October 2010.

11. DOH/UNICEF, An Assessment of the MARCY Youth Club program in the Philippines, August 2012.

12. WHO Regional Office for the Western Pacific Region (2009). Health Sector Response to HIV/AIDS among Men who have Sex with Men: Report of the Consultation. Manila, the Philippines. Available at: www.wpro.who.int/sites/hsi/documents/msmreport_feb2009_hok.htm 13. WHO (2010). Priority HIV and Sexual Health Interventions in the Health Sector for Men who Have Sex with Men and Transgender People in the Asia-Pacific Region.

Geneva, Switzerland. Available at: http://www.wpro.who.int/sites/hsi 14. PEPFAR. Technical guidance on combination HIV prevention. As part of PEPFAR’s overall prevention strategy, this guidance document addresses prevention programs for Men Who Have Sex with Men. May 2011.

Peer reviewed articles 15. Lucea MB, Hindin MJ, Gultiano S et al. The context of condom use among young adults in the Philippines: Implications for HIV prevention. Health Care Women Int. 2013 March; 34(3-4): 227–248.

16. Ross A GP, Ditangco RA, Belimac JG et al. HIV epidemic in men who have sex with men in Philippines, The Lancet Infectious Diseases, 13, 6, 472 - 473, 2013

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17. Urada LA, Morisky DE, Pimentel-Simbulan N, et al. Condom Negotiations among Female Sex Workers in the Philippines: Environmental Influences. PLoS ONE 7(3): e33282. 2012.

18. Bosch X: HIV mystery in the Philippines. The Lancet Infectious Diseases 2003, 3:320.

19. Farr A and Wilson DP An HIV epidemic is ready to emerge in the Philippines. J. of the Intern AIDS Soc 2010, 13:16 http://www.jiasociety.org/content/13/1/16 20. Godwin P, Dickinson C. HIV in Asia, Transforming the agenda for 2012 and beyond.

Report of a joint strategic assessment in ten countries. Health resource facility, June 2012.

21. Rationalization plan of PNAC Secretariat, PNAC 2014

Other working documents reviewed Pilar Report; Geroche Report Monitoring and Evaluation System report (PNAC Secretariat) Annual Accomplishment Reports (PNAC Members) UNDAF Report, 2013 Summary of Capacity Building Activities on M&E ,PNAC Secretariat Summary of Major Initiatives of Council Members, 2011 PNAC Resolution No. 0704-1 Investment Plan for HIV & AIDS (working draft), 2012 HIV Reports â&#x20AC;&#x201C; RAAT10, 2012 Candlelight Memorial Report from Gingoog City & Malaybalay City Accomplishment Report 2011 - 2012 PNAC Action Plan of Activities, 2010, 2013 Terminal Report on IACMM, 2011 Caloocan Annual Investment Program 2014 Functional Statement CHD Metro Manila Activity Report National STI, HIV & AIDS Control Program, 2012 Annual Report Special Joint SDC-HDPR Meeting on the PHL 5th MDG Program Report

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ANNEX 4 Proposed PNAC organigrams and Terms of reference for Working Committee on Localization & Convergence 1. Proposed PNAC Organigram a) ED of the Secretariat must be a regular member of the Execom. In the manual of operations, we need to articulate more powers & responsibilities of the ED. b) TWCs shall be composed of volunteer member organizations of the Council and shall assume support functions. Each TWC shall have a support complement from the Secretariat to assume the following functions: c) Administrative assistance in all activities to be undertakenâ&#x20AC;&#x201D;logistics, documentation, communications, coordination among members d) Monitoring of the plans made by the TWC e) The four (4) Working Groups on the Health Sector, Policy, PNAC restructuring and the Localization & Convergence shall be composed of Council member organizations and in the case of the LC, representatives from LGUs and CSOs/CBOs from Categories A&B . Each working group shall be co-convened by a CSO representative who shall enjoy the same powers & responsibilities as the lead convenor. f) Proposed focus of operational plans for Policy WG is the amendment of the PNAC law, Health Sector on the recommendations of the midterm review and the LC on activating & strengthening the LACs and the RAATs as support and technical guidance.

2. Terms of Reference for the Working Committee on Localization & Convergence The Localization and Convergence Committee shall replace the Partnership, Networking & Advocacy Committee which performs a line function in terms of performance of tasks and responsibilities that shall directly contribute to the achievement of the 5th Strategic Objective.

It shall be composed of representatives of strategically identified LGUs and community-based organizations (CBOs) from Categories A&B to be led by the DILG. It shall ensure that as co-drivers of the national response, LGUs and CBOs through the LACs, with able assistance from the RAATs, local communities design and implement a clear, cohesive plan localizing the implementation of the AMTP5 for the next three years, with clear, attainable and measurable indicators of performance. Furthermore, this Committee shall oversee the effective and timely convergence and interfacing of all HIV/AIDS-related projects, services and activities of the various national government agencies and civil society organizations.

This Committee will ensure that participatory mechanisms for the formulation of policies, plans and programs responsive to local needs and national priorities are

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established. Further, this committee will ensure that the venues for increased peopleâ&#x20AC;&#x2122;s voice in decision making starting with the formulation of Local AIDS Action Plans through the Local AIDS Councils are present and that more local convergence groups are organized and are active. Capacity building needs shall be identified and activities implemented for the LACs with assistance from the Capacity Development TWC of the Secretariat. LACs will also be capacitated on the generation and utilization of local data and information provided for by the Strategic Information TWG of the Secretariat.

PROPOSED ORGANIZATIONAL STRUCTURE

PNAC SECRETARIAT ORGANIGRAM

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ANNEX 5. Research Issues Below is a non-prioritized list of research topics that appeared to the review team to be worthy of consideration.

Prevention for MARPs/ key populations at risk Evaluation research to assess the effectiveness of all interventions being directed to key populations Evaluation of Social Hygiene Clinics’ services for all key populations Decentralization of HIV testing and counselling among key populations: development of a community- based model with strong linkages to ARV treatment and care; development of an HIV testing algorithm for key populations Operational research on peer education for key populations Operational research to improve coverage of outreach, testing and returning for results Prevention for most at risk populations: PWID Understanding the barriers and facilitators of injecting in Cebu. What has given rise to injecting there and why has it remained there and not spread to other cities?

Analysis of IHBSS data on needle sharing Does OST work for Nubain which is used by most PWID in Cebu?

Operational research on a 'Test and Treat ' model among PWID Determinants of adherence to treatment among PWID; operational research to improve treatment adherence Understanding effectiveness NSP to reduce spread of infection Qualitative research on uptake and use of sterile needles Prevention for most at risk populations: MSM Operational research on a 'Test and Treat ' model among MSM Defining sub-populations of MSMs, describing the social and behavioural characteristics and health seeking behaviours.

Mobilizing and reinforcing community leadership among MSM to induce positive changes in community norms and behaviors (Key Opinion Leaders) Determinants of adherence to treatment among MSM Prevention for most at risk populations: FSW Assessing the impact of mandatory visits by registered female sex workers to social hygiene clinics on the spread of STIs and HIV, and on preventive behaviour in general, especially condom use Mapping risk factors for STIs and HIV among non-registered (“free-lance”) female and male sex workers Developing an evidence-base for sex worker interventions: validation of STI screening algorithm for sex workers and modelling of cost effectiveness of weekly, biweekly, monthly and quarterly visits.

What should be the optimal package of services offered to registered sex workers by the social hygiene clinics?

How to incentivize regular visits to social hygiene clinics by registered female sex workers other than through registration?

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Prevention for Most at risk population: Transgender people Development of essential HIV and STI service delivery models to address special service needs for transgender people HIV testing and counselling, treatment, care and support Develop estimates and projections of ART care needs through 2016 in the light of current trends in case detection and the anticipated change in CD4+ count threshold from 350 to 500 Prospective cohort analysis to evaluate the cascade between HIV testing and treatment and care (Cox proportional hazard model) Cost-effectiveness analysis on decentralization/scale up of treatment services (addressing the large gap between the number of HTC and Treatment hubs) Developing an operational model for the efficient and effective deployment of mobile VCT Tracking the treatment cascade: managing and evaluating the continuum of HIV prevention, care and treatment Qualitative research to clarify the reason why patients are becoming lost to follow up Mortality study of AIDS deaths using verbal autopsy Clinical services: other issues Evaluating the quality of HIV care offered by public and private clinicians Identifying the reasons for high false positive HIV testing (30% in 2012) in private laboratories Factors impeding the introduction and use of rapid tests for STIs How to avoid high staff turnover: incentives to ensure greater staff retention in STI/HIV public health services?

Vulnerability: Evaluating the impact of the anti-child trafficking and sexual exploitation laws in preventing the sexual exploitation of under-age sex workers and on the ability to effectively engage unregistered adult sex workers in HIV prevention services

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Annex 6. Key informants Team A 1

CAR

Baguio City

2

CAR

Baguio City

3

CAR

Baguio City

4

CAR

Baguio City

5

CAR

Baguio City

6

Region III

7

Region III

8

Region III

Angeles City Angeles City Angeles City

9

Region III

10

NCR

11

NCR

12

NCR

Angeles City Paranaque City Paranaque City Quezon City

13

NCR

Manila

14

NCR

Quezon City

15

NCR

Manila

16

NCR

Quezon City

17

NCR

Manila

18

NCR

Quezon City

19

NCR

Quezon City

20

Region IVB

21

Region IVB

23

Region IVB

Puerto Princesa City Puerto Princesa City Quezon City

24

NCR

Quezon City

25

NCR

Quezon City

26

NCR

Quezon City

Reproductive Health & Wellness Center CHD â&#x20AC;&#x201C; CAR

Celia Flor Brillantes, MD Julius Alcala, MD Marlene de Castro

RHWC Chief

LGU

Gov

Medical Specialist I

RAAT

Gov

Executive Director

NGO

NGO

"Ryan"

PLHIV

KAP

KAP

Paulynne Balajadia Lenario T. Santos, MD Mercedes S. Lozano Resurecion F. Alonzo

City Council Employee City Health Officer

LGU

Gov

LGU

Gov

Assistant Program Head Population Program Officer

LGU

Gov

LGU

Gov

Verona V. Guevarra, MD Olga Z. Virtusio, MD Karen Galvan, MD Austere Panadero Gerard Belimac, MD Marites Paneda

RHWC Chief

LGU

Gov

City Health Officer

LGU

Gov

RHWC Chief

LGU

Gov

Undersecretary

PNAC

Gov

HIV Program Manager Technical Representative Social Technology Representative

PNAC

Gov

PNAC

Gov

PNAC

Gov

Amara QuesadaBondad

Executive Director

PNAC

NGO

Eddy N. Razon

President

PNAC

NGO

Health Action Information Network (HAIN) Health Action Information Network (HAIN) Puerto Princesa Social Hygiene Clinic

Edelina Dela Paz, MD

Executive Director

PNAC

NGO

Noemi B. Leis

Technical Representative

PNAC

NGO

Eunice Herrera

SHC Physician

LGU

Gov

Puerto Princesa Social Hygiene Clinic

Regina Villapa, RMT

Medical Technologist

LGU

Gov

DILG Regional Office 4B Quezon City Health Office Quezon City Health Office Bernardo Social

Lorenzo Suarez

RAAT Representative City Health Officer

RAAT

Gov

LGU

Gov

HIV/AIDS Program Coordinator SHC Physician

LGU

Gov

LGU

Gov

Baguio Center for Young Adults, Inc. (BCYA) Committee on Health and Sanitation Angeles City Health Office Angeles City AIDS Council Angeles City Health Office Population Division Reproductive Health & Wellness Center Paranaque City Health Office Reproductive Health & Wellness Center Department of Interior and Local Government Department of Health Philippine Information Agency Department of Social Work and Development Action for Health Initiatives, Inc. (ACHIEVE) Pinoy Plus Association

Elma Salamat

Annie Inumerable, MD Rolly Cruz, MD Ma. Suzelle

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Hygience Clinic

Encisa, MD

Bernardo Social Hygience Clinic Klinika Bernardo

John Kennedy Jardenil Leonel John Ruiz, MD Mariluz P. Tejares

Supervising Peer Educator SHC Physician

LGU

Gov

LGU

Gov

Deputy ED Manager ISEAN-HIVOS

NGO

NGO

Maria Paz G. De Sagun

Project Management Specialist Executive Director

Bilateral

NGO

Private

Senior Advocacy Officer PRSR

NGO

Private

NGO

Private

Ricardo J. Mateo, Sr.

Partnership and Advocacy Officer PBSR Senior Technical Officer, M& E

NGO

INGO

Department of Justice

Atty. Romeo Senson

State Prosecutor, Technical Rep

PNAC

Gov

Mandaluyo ng City

National Economic Development Agency

Edgardo Aranjuez

Supervising Eco Dpment Specialist

PNAC

Gov

NCR

Mandaluyo ng City

National Economic Development Agency

Arlene Ruiz

PNAC

Gov

38

NCR

Manila

Rodel G. Navarra

NGO

NGO

39

NCR

Manila

Ana Portia B. Carza

Programme Development Manager

NGO

NGO

40

NCR

Quezon City

Positive Action Foundation Philippines Inc. (PAFPI) Positive Action Foundation Philippines Inc. (PAFPI) House of Representatives

Chief Economic Development Specialist Executive Director

Maria Lourdes M. Sanchez

PNAC

Gov

41

NCR

Quezon City

House of Representatives

PNAC

Gov

42

NCR

Quezon City

House of Representatives

Atty. Frances Mae Cherrie K. Ontalan Cong. Eufranio C. Eriguel

Technical RepresentativeCom mittee Sec Chief of Staff

PNAC

Gov

43

NCR

Manila

Gov

NCR

Manila

Ferchito Avelino, MD Jon Fontila

PNAC

44

Philippine National AIDS Council (PNAC) GFATM-TFM

Chairman, Committee on Health Director III

45

NCR

Manila

Paulie Mora

Gov

NCR

Manila

Advocacy Marketing & Networking HR officer

PNAC

46

League of Cities of the Philippines DOLE-OSHC

PNAC

Gov

47

NCR

Manila

DOLE-OSHC

Gov

NCR

Manila

DOLE-Occupational Safety and Health Center (OSHC)

Occupational Health Officer Executive Director

PNAC

48

Dr. Daryl Bautista Dr. Ma. Teresita Cucueco

PNAC

Gov

27

NCR

Quezon City

28

NCR

Quezon City

29

NCR

Pasay City

30

NCR

Manila

31

NCR

Makati City

32

NCR

Makati City

33

NCR

Makati City

Pilipinas Shell Foundation

Julius Elopre, PTRP

34

NCR

Manila

FHI 360 Philippines

35

NCR

Manila

36

NCR

37

Philippine NGO Council on Population, Health and Welfare, Inc. (PNGOC) United States Agency for International Development (USAID) Pilipinas Shell Foundation Pilipinas Shell Foundation

Edgardo Veron Cruz Maria Stella G. Flores

Joyce Ann de la Cruz

Project officer

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49

NCR

Manila

Jonas Bagas

Executive Director

PNAC

Gov

Makati City

TLF Sexuality, Health and Rights Educators Collective Inc. (TLF SHARE) UNDP

50

NCR

Philip Castro

UNDP

DP

NCR

Makati City

UNAIDS

UNAIDS

DP

52

NCR

Social Hygience Clinic

LGU

Gov

54

NCR

City Health Officer

LGU

Gov

55

NCR

City Councilor

LGU

Gov

56

NCR

Caloocan City Caloocan City Caloocan City Mandaluyo ng City

Teresita Bagasao Zenaida Calupaz, MD Maybelle Sison, MD Hon. Aurora Henson, Jr. Queenie Lazaga, RN

PO on HIV Com Team Leader Country Coordinator SHC Physician

51

Site Coordinator, Nurse II

RAAT

Gov

57

Region X

OIC, City Health Officer SHC Physician

LGU

Gov

59

Region X

President

NGO

NGO

60

Region X

Rachel Daba Dilla, MD Joselito A. Retuya, Jr., MD Fritzie CaybotEstoque Mira G. Yee, MD

Gov

Region X

Cagayan De Oro City Health Office Cagayan De Oro Social Hygience Clinic MOCAN

LGU

58

Cagayan De Oro City Cagayan De Oro City Cagayan De Oro City Cagayan De Oro City

Officer, Chapter Administrator

NGO

NGO

64

Region X

Cagayan De Oro City

Evelyn Magsayo, MD

HIV Program Manager

RAAT

Gov

65

Region X

Rosemarie Echavez Daisy Ramos

RAAT

Gov

Region X

DILG Regional Office 10 DSWD Field Office 10

LGOO V

66

Social Worker

RAAT

Gov

67

Region X

CHD – 10

NGO

NGO

69

Region X

Infectious Disease Nurse Advocacy & Networking Staff Chairperson

Gov

Region X

Chuck Casino, RN Lerio T. Chua

RAAT

68

Cagayan De Oro City Cagayan De Oro City Cagayan De Oro City Cagayan De Oro City Cagayan De Oro City

NGO

NGO

70

Region X

TISAKA

Chairperson

NGO

NGO

71

NCR

Cagayan De Oro City Quezon City

RH/HIV Focal Person

PNAC

NGO

Caloocan City Health Office Committee for Health and Sanitation CHD – NCR

Philippine Red Cross – Misamis Oriental – CDO Chapter CHD – 10

ALAGAD Mindanao, Inc. Tingug – CDO

Trade Union Congress of the Philippines (TUCP)

Reynante Pacheco Namocatcat Eleony A. Monding Alex V. Rutagines

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Team B 17 October 2013 1. Health Policy Development and Planning Bureau (DOH-HPDPB) 18 October 2013 2. Bureau of International Health Cooperation (DOH-BIHC) 3.

Philippine Health Insurance Corporation (PHIC, PhilHealth), Pasig City

4.

Bernardo Social Hygiene Clinic, Quezon City

19 October 2013 5. Research Institute for Tropical Medicine (RITM) Satellite Clinic, Manila

6.

Manila Health Department and Manila Social Hygiene Clinic, Manila

7.

AIDS Society of the Philippines, Quezon City

21 October 2013 Cebu

Dr. Marwynn Bello (Division Chief)

Dir. Maylene Beltran (Director IV)

Dr. Mary Antonette Remonte (MDG Team Leader) Dr. Lizelle Lagrada (Officer-in-charge, Vice President) Dr. Rolly Cruz (Quezon City HIV/STI Coordinator) Mr. John Jardenil (Peer Educator Supervisor for Quezon City) Mr. John Dave David (Peer Educator) Mr. Jason Sepino (Peer Educator) Mr. Philip Tanpoco, Jr. (Program Coordinator, AIDS Research Group) Mr. Christopher Lagman (Director of Learning and Development) Ms. Marianne Ramos (Medical Technologist) Dr. Diane Mendoza (SHC Manager) Dr. Rosalina Tan (MCH (Maternal and Child Health) Coordinator of Manila Health Department) Dr. Jonathan Fontanilla (Global Fund Transitional Funding Mechanism Coordinator) Mr. John Torres (Peer Educator) Mr. John Lenard Cortes (Nurse) Ms. Anika dela Merced (Site Implementation Officer (SIO)/ Peer Educator Supervisor) Dr. Leonora Barboza (Administrative Officer) Ms. Cecil Anonuevo (Program Manager) Mr. Jose Bayani Velasco (Monitoring and Evaluation Officer) Ms. Christelle Sotello (Nurse, Icon Clinic) Ms. Vivien Santos (Medical Technologist) Dr. Nerissa Sescon (Physician, Icon Clinic)

8.

Cebu City Health Office

Dr. Stella Ygona (Cebu City Health Officer)

9.

Bureau of Jail Management and Penology (BJMP) Regional Office VII

Jail Supt. (Fr.) Bartolome C. Sasadal, MD (Assistant Regional Director for Operations, Prison - Chaplain) Jail Supt. Dr. Priscillana Lee Gilboy (Medical Officer for BJMP VII, Prison Development Officer and Medical Doctor) Jail Supt. (Fr.) Bartolome C. Sasadal, MD (Assistant Regional Director for Operations,

10. Cebu City Jail - Male, Female and Operation

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Second Chance (minor offenders)

Iloilo

11. Center for Health Development – Western Visayas

12. Western Visayas Medical Center

Davao

13. Center for Health Development – Davao Region

14. Southern Philippines Medical Center (SPMC)

22 October 2013 Cebu

15. Vicente Sotto Memorial Medical Center (VSMMC) – Treatment Hub

16. Cebu City Social Hygiene Clinic 17. Mandaue City Health Office and Mandaue City

Prison - Chaplain) Jail Supt. Dr. Priscillana Lee Gilboy (Medical Officer for BJMP VII, Prison Development Officer and Medical Doctor) JO3 Armando Novela (Nurse Male Jail) JO3 Nanette Bolodo (Nurse Female Jail) Dr. Maria Sophia Pulmones (Cluster Head, Infectious Disease and Environmental and Occupational Health) Ms. Charity Perea (NASPCP Coordinator) Mr. Rodolfo Chin, Jr. (HIV & STI Surveillance Assistant) Dr. Jose Mari Fermin (Hospital Director) Dr. Ray Celis (HIV & AIDS Core Team (HACT) Physician/Medical Specialist III) Ms. Eden June Simora (HACT Nurse) Ms. Charro Love Perea (Project Aide III) Mr. George Bartolome, III (President, United Western Visayas, Inc.) Dir. Abdullah Dumama (Regional Director) Ms. Myrna Aida Macayra (Regional HEPO (Health Education and Promotion Officer; RAAT (Regional AIDS Action Team) Point-person) Ms. Clarisse Andong (HIV/STI Surveillance Assistant) Mr. Geofford Montejo, Jr. (Nurse IV, Assistant NASPCP Coordinator) Dr. Leopoldo Vega (Chief of Hospital III) Dr. Alicia Layug (HACT Chair) Mr. Eric Prias (Nurse) Ms. Evelyn Aranola (Social Worker) Ms. Maria Fatima Pemi (Project Aide III) Ms. Julie Anne Gabawan (Nurse) Mr. JC Loren (HACT Personnel) Dr. Ian Jun Querubin (Treatment Center Head, PMDT (Programmatic Management of DrugResistant Tuberculosis)-SPMC) Ms. Jean Piqueño (Nurse I – OIC) Ms. Celenia Delima (Nurse) Ms. Gina Rulete (Nurse) Dr. Chamberlain Agtuca, Jr. (HACT – HIV AIDS Core Team (HACT) Asst. Chair) Dr. Abelardo Alera, Jr. (HACT Leader) Ms. Cindy Reformina (SIO-TCS (Treatment Care and Support), Cebu Plus Association Inc. Staff) Ms. April Matutinao (Project Aide) Dr. Ilya Tac-an (SHC Manager)

Dr. Edna Seno (City Health Officer) Ms. Elma Gonzales (Medical Technologist)

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Social Hygiene Clinic 18. Cebu Plus Association Inc. (CPAI) (2 Offices: VSMMC and Cebu City Health Office) 19. The Rehabilitation Center, Argao City

Iloilo

20. Iloilo City Health Office 21. Iloilo City Social Hygiene Clinic

22. St. Paul’s Hospital Iloilo

Davao

23. Reproductive Health and Wellness Center (RHWC) (formerly Davao City SHC)

24. Alliance Against AIDS in Mindanao, Inc. (ALAGAD) 25. Private Infectious Disease Physician 23 October 2013 Cebu

Iloilo

Mr. Tomas Jonathan Refe (Program Director and Senior Nurse) Ms. Josefel Chua (Administrative Officer and Social Worker) Dr. Urminico Baronda, Jr. (City Health Officer) Dr. Ma. Odeta Villaruel (SHC Physician) Ms. Razel Portugalete (SHC Nurse) Ms. Virgie Advincula (Behavior Change Communication Coordinator) Mr. Romeo Bordamonte (Peer Educator) Dr. Ellamae Divinagracia (HIV & AIDS Core Team (HACT) Physician) Ms. Ana Joy Jamera (HIV Proficient Medical Technologist) Ms. Jocelyn May Millan (Infectious Disease Nurse / HACT Nurse) Sr. Marilyn Rigor (HIV Proficient Medical Technologist) Dr. Josephine Villafuerte (City Health Officer) Mr. Patrick Albit (SIO-GF) Mr. Eddie Batoon (SIO-GF) Ms. Ambeth Laganzo (Peer Educator) Mr. Nathaniel Malinao (Peer Educator) Mr. Erwin Suarez (Peer Educator) Mr. Nick Reyes (Peer Educator) Mr. Jims Rivera (Peer Educator) Ms. Alma Mondragon (Executive Director) Ms. Connie Ailut (Care and Support) Ms. Michael Jesus Mahinay (Project Officer) Dr. Pamela Ferrer (Private Physician – Infectious Disease)

26. Center for Health Development – Central Visayas

Dr. Jonathan Neil Erasmo (STI-HIV Coordinator)

27. PhilHealth Region VI Office

Dr. Bernadette Reynes (Chief of the Health Care Delivery Management Division) Mr. Romel Dilag (Chief of the Membership Division) Prof. Nennalyn Abioda (Exective Director) Ms. Melba Sale (Healthcare Service Provider)

28. Kabalaka Reproductive Health Center Davao

Dr. Debra Catulong (SHC Physician) Ms. Conchita Icalira (SHC Midwife) Mr. Floyd Maldepeña (Satellite Treatment Hub Nurse) Mr. Nathan Navarette (Peer Educator) Ms. Jasil Villares (SIO-CPAI)

29. Mindanao AIDS Advocates Association,

Mr. Midgie Tindoc (President)

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Inc. (MAAI) 24 October 2013 30. National Epidemiology Center (DOH-NEC)

31. AIDS Research Group (ARG), Research institute for Tropical Medicine (RITM), Muntinlupa City

32. Department of Budget and Management, Manila 33. Makati City Health Office, Makati City Social Hygiene Clinic, Makati City 34. Makati Medical Center, Makati City

35. Pasay City Social Hygiene Clinic and Health Center, Pasay City 36. Pasay City Antenatal Clinics, Pasay City

37. Positive Action Foundation Philippines Incorporated (PAFPI), Manila

25 October 2013 38. National Center for Disease Prevention and Control (DOH-NCDPC)

39. National AIDS and STI Prevention and Control Program (DOH-NASPCP)

Mr. Noel Palaypayon (Supervising Health Program Officer) Dr. Marlene Bermejo (HIV Surveillance Database Supervisor) Ms. Krizelle Anne Ronquillo (Project Associate III) Ms. Jessica Raphaela Mirano (Project Associate III) Mr. Geoffrey Garcia (Project Assistant III) Mr. Juan Carlos Miguel Camacho (HIV Surveillance Assistant) Dr. Rossana Ditangco (Chair) Ms. Rosa Lyn Bantigue (Data Manager) Mr. Roldan Bucal (Project Assistant III) Dr. Frank Anthony Wico (Physician, ARG Clinic) Ms. Clara Francesca Roa (Nurse) Ms. Janelle Pasajal (Nurse) Ms. Pamela Nicole Jumonong (Nurse) Mr. Raymon Lumanlan (Nurse) Ms. Nikka Martinez (Nurse) Ms. Cleopatra Bernardino (Chief, Management and Planning Specialist, Bureau B) Dr. Diana Jocelyn Va単o (City Health Officer) Dr. Bernard Sese (SHC Physician) Dr. Corazon Salinas (SHC Physician) Dr. Janice Caoli (Clinic Officer) Mr. Adrian Joseph Anbochi (HACT Nurse) Ms. Mercedita Marcestra (SIO) Dr. Joan Carlota Ranieses-Santos (SHC Manager) Ms. Marie Pierre Parlade (Nurse SHC) Dr. Grace Salle-Noble (MCH Coordinator/ Health Center Physician) Ms. Marcia de Dios (Medical Technologist, Health Center) Mr. Boying (Laboratory Aide) Mr. Rodel Navarra (Executive Director) Ms. Ana Portia Banal-Carza (Administrative Staff) Ms. Rosemarie Barrientos (Administrative Finance Officer) Ms. Elsa Chia (PA for Implementation) Dr. Irma Asuncion (Director IV) Dr. Jose Gerard Belimac (Program Manager, National AIDS and STI Prevention and Control Program (DOH-NASPCP)) Dr. Jose Gerard Belimac (Program Manager, DOH-NASPCP) Ms. Helen D. Paa単o (Project Associate III, DOHNASPCP)

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40. STD AIDS Cooperative Central Laboratory (SACCL), Manila

Dr. Arlan Lopez (Medical Specialist II) Ms. Susan Leano (Chief Medical Technologist)

41. H4 Pavillion, San Lazaro Hospital, Manila

Dr. Rosario Abrenica (Medical Specialist II, HIV/AIDS Core Team (HACT) Leader) Ms. Lorraine Anderson (Executive Director)

42. Precious Jewels Ministry, Extended Child Care Center, San Lazaro Compound, Manila 43. TB-DOTS (Directly Observed Treatment Short Course) Facility, San Lazaro Compound, Manila

Dr. Flora Marin (TB-DOTS Physician) Mr. Luisito Manuel (TB-DOTS Nurse)

44. Pinoy Plus Association, San Lazaro Hospital,

Mr. Edu Razon (President)

45. Philippine NGO Council on Population Health and Welfare, Inc. (PNGOC), Pasay City

Dr. Grace Chan (Program Manager, ISEAN-Hivos) Mr. Mario Balibago (Program Officer, FHI360 ROMP)

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