PREVENTING HIV TRANSMISSION /23
Preparing for the unknown / 24 Setting up a peer education program / 26 Effective change through peer education / 28 Passing on the message / 28 Protecting oneself to protect peers / 28 A calling / 29 Organizing the party / 29 Mr. Clean and the freelancers / 30 Migrant workers can be vulnerable to HIV / 32 OFW forum / 32 Breakthrough in backdoor migration / 32 Halao / 33 Migrant desks / 34 Preventing mother to child transmission of HIV / 35
pre venting hiv through sti CONTROL and condom use / 37 Agents of change / 38 Reaching out and expanding / 39 No condom, no sex / 40 Striving to make a change / 40 Choosing option C / 40 Becoming part of the common good / 41 A peer educator in every establishment / 41 It could happen / 41 Pushing for behavior change and social responsibility / 42 Organizing games / 43 Confronting vulnerabilities / 44
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PREVENTING HIV BY ENSURING BLOOD SAFETY / 45
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HIV prevention through voluntary blood donation / 46 The Share 15 Club / 50 Blood Olympics / 51 One for three / 52 How is it like being a Muslim working in a HIV project? / 53
EXPANDING VOLUNTARY COUNSELING AND TESTING / 55
Service beyond women entertainers / 56 The pillar of HIV prevention / 58
Service with confidentiality and care / 59 VCT in outreach / 60 Revelations / 60 Linking with communities / 61 Making positive change / 62 Coming home to advocate for HV prevention / 63
TREATMENT, CARE AND SUPPORT / 65
Empowering persons living with HIV / 66 Living with the virus / 68 Positive feelings / 69 An awakening / 70 The heart of treatment, care and support for people living with HIV / 71 Understanding stigma and discrimination / 73 Free ARVs / 74 Out and about / 75
GENERATING SUPPORt for greater response / 77
Accepting greater challenges / 78 Teaching responsible sexual behavior / 78 Proud of peers / 78 The reminder / 78 Moving forward / 79 Accepting greater challenges / 80 Ingat Lagi: The medium and the message / 80 New cases, new hopes / 80 Multisectoral involvement beyond health / 81 Working with NGOs / 82 Networking / 93 PLHIV as partners / 84 HIV and faith: Sexuality is God’s gift to human beings / 85
EVENTS / 86
Lighting candles for AIDS advocacy / 87 World AIDS Day / 88 10,000 Signatures / 89 STI convention / 90 Annual Partners Meeting / 91 GFR6 participates in 9th ICAAP /2
THE WAY FORWARD / 93 GFR6 Directory of VCT Trained Counselors / 97
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Table of Contents / 2 Foreword / 4 Acknowledgment / 5 The Editorial Board / 6 PROLOGUE / 7 THE MONOGRAPH / 8 THE PROJECT / 9 ON THE VERGE OF AN EPIDEMIC / 17
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T
he present times can be described as the most challenging over the past two decades, dating back to the time when the country first launched concrete measures to control the scourge of HIV/AIDS. The startling upsurge in the number of HIV/AIDS cases in the Philippines during the past year is a reminder that the task at hand is daunting and difficult. But it is also a call to double our efforts to battle the spread of the disease. We should not be intimidated nor lulled into apathy and inaction. We should commit to continue what we have started, and take bolder steps to address the issue. We will expand and strengthen counseling and testing, as well as preventive services. We will improve treatment, care and support services. We will dismantle the barriers of discrimination and misinformation. I take pride in the efforts that we have made collectively, including the production of this monograph, a first attempt at preserving the history of the experiences of people and organizations all over the Philippines who have responded to the call to action. The monograph details the comprehensive effort to improve HIV services, systems and mechanisms in the country funded by the Global Fund through the GFR6 HIV Project.
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May this repository of lessons remind us of the triumphs and achievements we have gained in the fight against HIV/AIDS, and inspire us to remain ready and steadfast to face the challenges that lie ahead.
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DR. ESPARANZA I. CABRAL Secretary Department of Health
ACKNOWLEDGMENT
T
his monograph would not have been possible without the inspiration provided by all the people and organizations working on HIV and AIDS prevention in the DOH-GFR6 HIV Project sites, especially the local government units, non-government organizations and the individuals whose lives have improved with the Global Fund support. Special thanks go to the Global Fund to fight AIDS, Tuberculosis and Malaria for its support to the Philippines through the DOH-GFR6 HIV Project. Dr. Yolanda Oliveros for taking the lead in tapping the resources of the GFATM and for providing technical directions in Phase 1 of the Project, specifically in the HIV component. Thank you to Dr. Criselda Abesamis for providing technical supervision in the blood safety component and to Dr. Eric Tayag for his technical expertise in surveillance. Acknowledgments are given to the contributors from the project sites, local government units and partner NGOs who took time to share what they have experienced and what they have achieved in improving care and support for people living with HIV, advancing voluntary counseling and testing and in the overall advocacy for HIV prevention. Appreciation to the AIDS Society of the Philippines for coordinating the development of this publication. Finally, many thanks to the persons who put human faces to the stories in this monograph, both for those who were willing to be identified and those whose real identities could not be mentioned.
Disclaimer This monograph is the initial publication in a series and it does not capture the whole spectrum of relevant experiences. Continuous efforts are being made to document practices to be showcased in succeeding monographs. The DOH, through its editorial team, tried to provide accurate information to document experiences. The views represented here are those of the authors and contributors and do not necessarily reflect those of the DOH, GFATM or the LGUs mentioned.
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foreword
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The Editorial Board
PROLOGUE
Editors Eduardo C. Janairo, MD, MPH Director IV, National Center for Disease Prevention and Control
DOH Global Fund Round 6 HIV Project
Mario S. Baquilod, MD, MPH Division Chief, Infectious Diseases Office, NCDPC
Maylene Beltran, MPA Director IV, Bureau of International Health Cooperation and Project Manager
Jose Gerard Belimac, MD, MPH Program Manager, National AIDS/STI Prevention and Control Program
Joel Atienza, RMT, MPH Technical Component Manager, HIV Prevention
Joel Atienza, RMT, MPH Supervising Health Program Officer, NASPCP
AIDS Society of the Philippines Jose Narciso Melchor C. Sescon, MD, FPOGS President
Jeniffer Cuneta- Feliciano, MD, MOH Technical Component Manager, Treatment, Care and Support Lawrence Sabido, MD, MPH Technical Component Manager, Surveillance and Research Maritess Estrella, RN, MM Technical Component Manager, Blood Safety
Glenn Cipriano Catubig Executive Director
Editorial Team
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Contributors and Coordinators
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Alicia B. Balacaoc Bric Bernas Sylvestra Freita Bautista, MD Elsie Dimarucot Anna Leah Dilangalen Dipatuan Jason Encabo Ramil Esguerra Humphrey Gorriceta Mona Lisa de Leon-Morales Helen Paano Mariano Jessie Padilla Serge A. Pontillas Nelson Yap
Diana G. Mendoza Editor
Marries Concepcion
Writer/Editorial Support Staff
Jennifer T. Padilla Design Artist
Jose Bayani M. Velasco
Information Technology Officer
This monograph is the first in a series of publications that highlights the mix of different colors, facets and movements of people at a time when the Philippines is at a junction of a disturbing HIV and AIDS epidemic. Stories tell the struggles of public and private organizations, ranging from the efforts of individuals who wanted to make a difference, accounts of awakenings and life-changing moments, to expressions of hope for possibilities that somehow, they can turn back the terrifying epidemic staring at them. Read about the experiences of peer educators who underwent difficult processes within themselves to be able to become instruments of change among their peers. Read how non government workers created bridges so that communities and individuals can see a common ground and act in unison. Have a look at the experiences in city and municipal health services and the people behind them, and glimpse at the events that mounted campaigns to bring more and better information to people. As this monograph was being prepared and as the stories kept coming, the proportion of Filipinos being infected with HIV has not slowed down. This monograph provides evidence that there are efforts to caution the effects of HIV infection and prevent another infection from happening. It hopes to generate more interest and foster committed efforts in HIV and AIDS advocacy from all Filipinos.
There are many stories that are worth telling and need to be told. The retelling starts with this monograph.
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Jaime Lagahid, MD, MPH Director III, Infectious Disease Office, NCDPC
A Retelling of People’s Stories
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THE PROJECT
STEPS: Outpacing the Epidemic may not be a giant leap, but it is the first big stride in sharing the lessons and experiences in knowing and cushioning the impact of HIV and AIDS, improving the quality of life of people living with and those affected by the virus, and changing the course of the epidemic in the Philippines. While the country’s rate of infection continues to jump, STEPS, which was conceived and laid out amid the climbing numbers, is an attempt to continue to go forward, though in little paces. There have been many initiatives implemented in the past, but not all of the good experiences were documented to guide the crafting of more effective interventions. Projects modeled key ingredients and impacted on particular groups, but still, country efforts that operated on a wider scope were limited. In documenting the experiences in this monograph, it is worthy to note that there have been stepping stones out of stumbling blocks, and that wrong attempts were considered steps forward, because every stakeholder believes that with every step, the value of the first is enhanced. It is in this context that this monograph series was conceptualized. As more experiences are shared in implementation strategies and processes, coordination mechanisms, shared feelings and insights, challenges and lessons learned, this series wishes to influence courses of action, policy development, and program enhancements to change the course of the country’s HIV epidemic. At the forefront of the health sector response to the HIV epidemic is the National AIDS/STI Prevention and Control Program (NASPCP) of the Department of Health (DOH). The driving forces behind this response are the local government units (LGUs) and community based organizations. The NASPCP has a lean team of technical officers who ensure program coordination with regional offices through the STI coordinator, program and policy development, provision of the technical assistance including resource mobilization, and monitoring and supervision. Aligned with NASPCP strategies, thrust and intervention framework, STEPS focuses on efforts towards encouraging community participation.
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Community participation and strategic information
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Expanding HIV testing and counseling Maximizing prevention Accelerating treatment scale up Strengthening health systems
Foremost among the stories in this monograph is the experience of the Global Fund Round 6 HIV Project (GFR6 HIV Project), a five-year grant implemented by the Department of Health, as the principal recipient. Funded by the Global Fund to Fight AIDS Tuberculosis and Malaria (GFATM), the Project’s goals are aligned to the 4th AIDS Medium Term Plan (AMTP4): to maintain a less than 1% HIV prevalence in the most at risk populations (MARPs), and to mitigate the impact of HIV among persons living with HIV (PLHIV).
The DOH-GFR6 HIV Project aimed to address four main objectives and 14 specific service delivery areas. The Project provides an appropriate mix of interventions and delivery of information to the MARPs -- registered female sex workers (RFSW), freelance sex workers (FSW) and their clients, men who have sex with men (MSM) and overseas Filipino workers (OFWs). It ensures HIV-free blood supply and prevents mothers who are HIV positive from transmitting HIV to their infants. The Project promotes voluntary blood donation and testing of blood supply for HIV and other blood transmissible infections. Treatment, care and support are scaled up in 13 treatment hubs in partnership with civil society organizations and the PLHIV community to provide life-saving medications, basic care and psychosocial support, including livelihood and empowerment. The Project also addresses health systems strengthening through capacity building, support to the improvement of delivery of services to social hygiene clinics (SHCs) and treatment hubs, development of referral mechanisms, and building partnerships. In 2006, increasing HIV cases were challenged by dwindling resources for interventions, uncoordinated and sparsely distributed projects and weak program structures and systems among coordinating agencies and partners. Concerns were expressed when HIV was relegated to the bottom of priorities, and it was compounded by religious opposition particularly from the Roman Catholic church to the use of condoms for HIV prevention. The health sector response was barely visible and lesser funded compared to a decade ago. There was a big clamor to put in more resources and further develop ongoing projects supported by GFATM Global Fund Rounds 3 and 5 under a different principal recipient. VCT and infrastructure were identified as gaps when free antiretroviral (ARV) drugs were introduced in the same year. Local governments’ budgets sparsely supported STI and HIV services. Social hygiene clinics focused on surveillance and expanded their reach to provide effective behavior change communication interventions on top of the regular diagnosis and treatment to registered establishment workers. To create a demand for VCT, the NASPCP developed a proposal with the goal of developing comprehensive and institutionally adapted project strategies that provide information and services to MARPs and vulnerable populations, HIV prevention among potential blood donors and in the blood supply, treatment and care for PLHIV and strengthening of the national, regional and local systems for the delivery of HIV related services.
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THE MONOGRAPH
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Proposal and Project Development Process
Service Delivery Areas
Person/Organization Involved
Agreement by CCM members to develop an HIV/AIDS proposal for Round 6
CCM
Organization of a DOH Technical Working Group for the VCT & Blood Safety Concept Development (weekly meetings)
CCM and DOH Core Group (NVBSP, NASPCP, PBC, PNAC, WHO, UNAIDS, GTZ)
Training of peer educators Institutionalized delivery of outreach services to clients of SHCs Training of migrant workers/families as advocates Establishment of migrant desks in 16 LGUs HIV prevention activities for migrant workers in 16 sites Monitoring and Supervision
CCM
Meeting of DOH group and Philippine Blood Center group (presentation of activities)
DOH Core Group
Meeting of DOH Round 6 proposal core group
DOH Core Group
Expansion of Core Group to civil society partners on proposal development
Expanded Core Group (Core Group plus PLHIV, 3 NGO representatives)
Approval by National Council for Blood Services Executive Committee
DOH with NCBS
Publication of Call for Concept Paper for Round 6
CCM
Approval of the proposal by DOH Secretary of Health and the Executive Committee
DOH Secretary and the Execom
Big Consultative Meeting of Stakeholders
Expanded Core Group
Procurement of kits and reagents for STI diagnosis Procurement of STI drugs Training for Comprehensive STI Case Management Innovative strategies for STI services (FLSW) Innovative strategies for STI services (MSM) National STI Convention/Forum Local Forum on STI/VCT Monitoring and Evaluation
Deliberation on the Submitted Concept Papers
Philippine National AIDS Council
SDA 1.3.: Voluntary Testing and Counseling (VCT)
Discussion and Approval of the HIV and AIDS Proposal
Philippine National AIDS Council
Presentation and Approval in (with revisions);
CCM
Referendum through the E-mail for final proposal approval
CCM
CCM Endorsement to GFATM
CCM
GFATM Secretariat Review
GFATM Secretariat
TRP Review
GFATM
Grant Implementation Negotiation Official Grant Signing
The Project commenced on December 1, 2007 in 16 major cities and municipalities around the country. Its implementation was subsumed under the health sector thrust of the sectorwide development approach for health that strengthens donor coordination and aid in prioritization of external resources. The DOH Bureau of International Health Cooperation spearheaded the grant management and complemented the coordination by management support services in finance, procurement and administrative services while the technical program components were implemented by programs. st e p s o u t p a c in g t h e e p i d e m i c
SDA 1.1. Behavior Change Communication: Community Outreach
Approval by CCM on the concept presented by DOH and an agreement in principle for DOH to act as PR for the Round 6 HIV/AIDS Component
Final Approval by TRP
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1. OBJECTIVE 1: Increased access of MARPS and general population to VCT in 16 sites
The implementation team was composed of the NASPCP under the National Center for Disease Prevention and Control for HIV and AIDS Prevention, Treatment and Care; National Voluntary Blood Services Program under the National Center for Health Facility Development for Blood Safety; and the National Epidemiology Center for HIV Surveillance and Research. The sub recipients and co-implementers were the AIDS Society of the Philippines (ASP), Remedios AIDS Foundation, Inc., (RAF) and the Positive Action Foundation Philippines, Inc. (PAFPI).
SDA 1.2. STI Diagnosis and Treatment
Training/Capacity Building: Basic VCT Training/Capacity Building: Proficiency Training for Medical Technologist (HIV Testing Licensure training) Training/Capacity Building: Target-specific VCT VCT: Development of External Quality Assurance system for VCT Infrastructure Support - for VCT at SHCs Infrastructure support - for VCT at Hospitals VCT: HIV screening and confirmatory kits VCT Promotion and Social Marketing (OFW/workplace) Monitoring and Evaluation SDA 1.4.: Prevention of Mother to Child Transmission Program
Grant Performance Indicator/s 1. Number of MARPS, (sex workers, MSM) reached by HIV/AIDS prevention activities 2. Number of condoms distributed to MARPs at SHC, outreach posts and by NGOs 3. Number of migrant workers and family members reached by prevention activities 14. Number of service providers trained including Peer Educators, Migrant Workers Associates) in conducting HIV/AIDS prevention education 4. Number and percentage of cases diagnosed and treated for STIs with counseling among the total consultations at the SHCs
5. Number of VCT centers supported at SHCs and hospitals (both public and private) 6. Number of people who received HIV counseling and testing and know the result
7. Number of HIV+ pregnant women receiving a complete course of anti-retroviral prophylaxis to reduce mother to child transmission
Development of national guidelines for PMTCT Development of training modules Popularization and implementation of guidelines Training on PMTCT Guidelines PMTCT services SDA 1. 5: Information System and Operational Research (Surveillance) Rapid Assessment Survey Integrated HIV Behavioral and Serologic Surveillance (IHBSS) Operational Research on developing strategy for sustainability of VCT and ART STI Etiologic Surveillance System IHBSS: Report Preparation and Reproduction IHBSS: Dissemination forums HBSS: Central Planning and Administration IHBSS: Management and Technical Review Establishment of Blood Bank Information System (IBBIS) Monitoring and Supervision
8. Number of intervention sites submitting quarterly reports on time to NEC (SSESS, inventory of drugs)
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Activity
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Grant Performance Indicator/s
SDA 3.1.: ARV Treatment and Monitoring
SDA 2.1.: Behavioral change communication - mass media PLWH Treatment and Monitoring Training/Capacity Building: Clinical Management of HIV/AIDS including ARVs ARV Provision {c/o GF 3 and 5 for Phase 1} Training/Capacity Building: Caring of Health Care Providers ARV Monitoring (Provision of CD4 Machines)
Advocacy: Public education and advocacy/information campaign Development of Video Materials (SHC and Blood donation clinics) Reproduction of Existing Video Materials for OFW Clinics Procurement of AV Equipments for SHC, Blood donation centers (Itemized/Separated from the previous activity) Development of Tri media campaign materials and air time including billboards Reproduction and Distribution of IEC materials Development, publication, reproduction & distribution of learning materials in schools including animation SDA 2.2.: BCC Community outreach (public education on voluntary blood donation , healthy lifestyle and HIV prevention).
SDA 3.2: Prophylaxis and Treatment of Opportunistic Infections (OI)
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Support to operations of the Phil. Blood Center, Sub-natl. blood centers and other blood service facilities in the 23 sites HIV Confirmatory (Western Blot) Hiring of Med Tech Hiring of Administrative Aide for PBC Blood Cold Chain: Transport Boxes Blood Cold Chain: Platelet Agitator Procurement of motorcycles for transport of specimen and blood units Support for the operations of centralized testing Total Quality Management (QAP, audit) Workshop on Basic Blood Bank procedures Consultative workshop in the revision of Manual of Standards for Blood Banks and Blood Centers, printing and distribution of manuals Conduct of EQUAS Assessment core team site visits to 4 selected 21 site Rational use of blood in hospitals Consultative workshop, meeting for CPG development, publication, distribution Training on rational blood use to 23 sites Pre and Post Donation counseling Training/year on pre & post donation counseling manual and use of blood donor data sheet Monitoring and evaluation
11. Number of Opportunistic Infections treated among PLHIV
PLWH Treatment and Monitoring Development of guidelines for use of vaccine Provision of vaccines for PLWHAs against infectious diseases (pneumococcal, influenza, chicken pox) 9. Number of people reached by public education (healthy lifestyle, voluntary blood donation, HIV/AIDS prevention
Community Education/Forum: PepTalk Human Resource: Incentives to Blood Donors Recruiter Medical Equipment for Blood donor screening Training/Capacity Building: Training of blood recruiters Training/Capacity Building: Echo Training on Donor recruitment Training/Capacity Building: Training on Blood Cold Chain SDA 2.3.: Blood Safety
Number of PLHIV enrolled in ARV treatment (Phase 2 only)
10. Number and percentage of donated blood units tested for HIV and other blood transfusion transmissible infections (TTIs)
SDA 3.3.: Care and Support for the Chronically Ill Training/Capacity Building: Micro entrepreneurial strategy for PLWHAs Enrolment of PLWHAs in social health insurance Referral to VCT/Treatment hubs (operationalizing of existing standards) ARV training for community workers National convention for PLWHAs Training/Capacity Building: Micro entrepreneurial strategy for PLWHAs SDA 3.4: Supportive Environment - Stigma Reduction Training/Capacity Building: Stigma reduction symposium in hospital care setting Training/Capacity Building: Stigma reduction symposium in community care setting 12. Number of PLHIV affected family receiving basic care and psychosocial support 13. Number of community members, including health personnel and government officials trained on prevention of stigma and discrimination against PLHAs
4. OBJECTIVE 4: Strengthened health systems for provision of HIV/AIDS services
Grant Performance Indicator/s
SDA 4.1: Supportive Environment - Coordination and Partnership Development
15. Number of service providers trained including SHC personnel, medical technologists and blood safety facility staff) in HIV/AIDS prevention education
Site Coordination (Salaries of SIOs) Advocacy: Big Advocacy Event (World AIDS Day, Candle light, local project launching) at local level Advocacy for Local AIDS Council and Local Blood Council. SDA 4.2: Supportive Environment - Strengthening of Civil Society and Institutional Capacity Building Advocacy - Annual Partner’s Meeting of Implementers Advocacy - Project Launching Training/Capacity Building M&E: Process Documentation, Reproduction and distribution M&E: External Evaluation of the Project M&E: PMO/CCM Project Monitoring & Evaluation M&E: TWG meetings/CCM PR Operating Cost
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2. OBJECTIVE 2: To reduce transmission of HIV among the blood donors
3. OBJECTIVE 3: Scaled up treatment, care and Grant Performance Indicator/s support for PLHIV, their families and significant others (national)
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The Project identified sites using the vulnerability criteria of the Philippine National AIDS Council, and these included eight LGUs previously supported by the USAID: the cities of Angeles, Quezon, Pasay, Cebu, Iloilo, Davao, General Santos and Zamboanga. The remaining eight were relatively new sites with or without previous donor support: the cities of Laoag, Tuguegarao, Santiago, Manila, Caloocan, Puerto Princesa, Butuan, and the municipality of Puerto Galera. The sites were complemented by identified referral facilities for hospital-based HIV counseling and testing and subsequent referral treatment hubs for ARV provision.
The Project delivered interventions in a complementary manner utilizing partnership, collaboration and leveraging resources among partner LGUs, NGOs and hospitals. VCT & ARV Services
Luzon
Treatment Hubs (ARV)
Social Hygiene Clinics
Hospital based VCT Center (GFR6)
Mindanao Davao Medical Center
ITRMC, La Union BGHMC, Baguio City CVMC, Tuguegarao San Lazaro Hospital RITM PGH JBLMMC BRTTH, Legaspi City
VSMMC, Cebu City
Laoag Tuguegarao Santiago Angeles Quezon City (3 SHC) Manila Pasay Caloocan P. Galera P. Princesa
Iloilo City
Davao City
Cebu City
General Santos
WVMC, Iloilo City CLMMMC, Bacolod
ZCMC, Zamboanga City
Zamboanga City Butuan City
JRRMMC, Manila JFMMC, Manila East Ave. MC, QC DMMMC, Caloocan ONA, Angeles City MMMC, Batac, Ilocos Ospital ng Palawan
Blood Service Facilities
The complexity of the identified strategies necessitated the development of the project implementation structure that supports the main objective of the NASPCP to strengthen the health systems for delivery of HIV services, which captures all aspects of prevention, treatment, care and support, shown in the GFR6 Operations Framework.
Visayas
Davao Regional Hospital CARAGA Regional Hospital Cotabato Regional Hospital
AUFMC, Angeles City BRH, Batangas City Bicol RMC, Legaspi CVMC, Tuguegarao City CHO Bauang, La Union ITRMC, San Fernando City, La Union JBLGH, San Fernando, Pampanga MMMMC, Laoag City, Ilocos Norte OMPH, Calapan, Oriental Mindoro PBC, Manila PNRC Baguio City PNRC Santiago City PNRC, Puerto Princesa City
EVRMC, Tacloban City
CRMC, Cotabato City
PNRC WVRBC, Iloilo City
CARAGA RH, Surigao City
Reg VII Blood Center, Cebu City WVRH, Bacolod City
DBC,Davao City PNRC, General Santos City PNRC, Cagayan de Oro City PNRC, Zamboanga City
Project Performance – Phase 1
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Period Rating
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
B1
A2
B1
B2
B1
B1
B1
no rating yet
Phase 1 covered 8 quarters from December 1, 2007 to November 30, 2009. Although the project started slowly in its organizational set-up including engagement of sub recipients, most of the indicators were achieved or over achieved compared to the targets, owing to strong programmatic delivery of targets except in distribution of condoms and the number of pregnant
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All GFATM supported projects are performance-based funding mechanisms with the Country Coordinating Mechanism (CCM) providing oversight function. Under an agreed performance framework, progress reports are prepared by the principal recipient and submitted to the CCM and the Technical Working Group (TWG) for further endorsement to the Local Fund Agent and to the GFATM Secretariat. The quarterly ratings of the GFR6 were: A1 highest – C lowest
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positive women provided with prophylaxis. Condom procurement delay caused the under achievement. There were no HIV-positive women needing prophylaxis during the whole duration of Phase 1 of the project, hence, it was considered as a negative indicator. In December 2009, Phase 1 was extended until March 30, 2010. To date, the performance in all of the targets per indicators intended for Phase 1 were accomplished, except for condoms and PMTCT. GFR6 accomplishment based on set targets as of Novermber 2009 (Q8) is as follows:
ON THE VERGE OF AN EPIDEMIC “Disturbing” was how HIV and AIDS advocates described the sudden rise of infections in the last few years up to the time this monograph was being prepared. The number of Filipinos getting infected continued to shoot up. From a low and slow level of epidemic for over 20 years since the first case in 1984, the picture of HIV infection in the Philippines drastically changed between 2006 and 2009 when more cases were reported annually: 309 in 2006, 342 in 2007, 528 in 2008 and 835 in 2009. “We are in ICU”, Dr. Eric Tayag, director of the DOH NEC, told a packed audience in December 2009 when he presented results of the IHBSS, comparing the Philippine HIV epidemic to a patient in critical condition at the intensive care unit.
The measurement of impact and outcome indicators set by the project is still ongoing under the Project- supported conduct of the Integrated HIV Behavioral and Serologic Surveillance System (IHBSS) led by the DOH National Epidemiology Center.
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Dr. Tayag said the AIDS registry showed a doubling time of every four years in the first decade since 1984. From 1995, the doubling time lengthened to 10 years as a result of comprehensive prevention and control programs, but between 2007 and 2009, the cumulative number of 4,218 cases in the October 2009 AIDS Registry showed a doubling time of only two years: In 2000, 1 new HIV case is reported every 3 days. In 2007, 1 new case is reported everyday, and in 2009, 2 new cases a day.
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Two new HIV cases a day
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Early in the epidemic, the number of OFWs was lower than non-overseas workers, but between 2000 and 2005, the number of OFWs increased to equal the number of nonOFWs. However, since 2006, majority of new cases being reported to the Registry are non-OFWs. In 2009, there were more non-OFWs in the registry. The October 2009 registry recorded a 21% rate, or 1 out of 5 of cases as OFWs. Of the 80 new cases, 69% were MSM and 31% were heterosexual. This would suggest an overall picture of MSM and heterosexual men with the ratio of 3:1. From 1984 to 2007, the main mode of transmission was heterosexual. From 2008 to 2009, MSM, homosexual, and bisexual contacts were predominant. The steep increase of infected MSM beginning 2006 and 2007 also showed a sudden shift in the mode of transmission. Up until 2007, a high rate of infection was concentrated only in highly urbanized areas of Metro Manila and Metro Cebu, but in 2008 and 2009, the list included Metro Davao.
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Dr. Tayag said the survey results showed the interplay of factors that drive the epidemic – “risky behavior, underachieved prevention coverage and the presence of at risk populations such as FSWs, MSM, IDU, clients of sex workers and the partners of each person in all of these groups.” Freelance female sex workers do not always access services of the SHCs, unlike registered establishment-based female sex workers who do so and benefit from the services. The MSM usually do not access SHC services, which lowered prevention. He added the low coverage of outreach activities, low distribution of products such as condoms or information materials, and difficulty of targeting hidden populations. Increasing rates of STIs among HIV-infected cases is
highest among MSM and IDU, in urbanized areas and among younger age groups. Among MARPs, multiple sex partners, unprotected sex, especially during anal sex, and sharing of needles are high. HIV surveillance was established in 1984. Periodic behavioral and serologic surveillance have been in place since 1993. In 2005, both components were integrated into one surveillance system. Thus, the first IHBSS round was conducted in 2005, the second in 2007, and the third in 2009. This third round measured behavioral risks through faceto-face interview and HIV and syphilis prevalence through blood extraction and testing. With support from the Global Fund Rounds 5 and 6 projects, the 2009 IHBSS included the original 10 sentinel sites: Baguio, Angeles, Cebu, Iloilo, Davao, General Santos, Zamboanga, Cagayan de Oro, Pasay, and Quezon City. The additional 13 include GFR 5 –supported sites Surigao, Makati, Marikina, Mandaluyong, Pasig, and eight GFR 6 sites Laoag, Tuguegarao, Santiago, Puerto Galera, Puerto Princesa, Butuan, Manila, and Caloocan. There were 14,976 respondents identified in the MARPs that included RSFWs, FSWs, IDU, and MSM; 9,000 were from the 10 sentinel sites that included 958 IDUs; and 2,259 from the GFR5 sites and 3,737 from the GFR6 sites. IDUs were neither interviewed nor tested in the two GFR sites. Determining correct knowledge between 2007 and 2009 included questions on sharing needles and if HIV can be contracted in public toilets and through mosquito bites. For the MSM, 70% had correct knowledge about needle sharing in 2007, but the figure dropped to 52% in 2009. Responses to the question if HIV can be contracted in public toilets improved along all MARPs, but very little among FSWs. For mosquito bites, knowledge improved at 98.5% correct, but there were sites that reported only 16.6%.
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From 2006 to 2007, males aged 30-34 and 25-29 year old females dominated the infected groups, but in 2008, the cases became younger -- 25-29 for males and females, with notable increases in males 20-24 years. In 2009, males and females who were 25-29, and younger males aged 20-24 caught up.
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From 7 to 70
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In the 2007 survey, seven tested positive among respondents. In 2009, there were 70 (46 males and 24 females), with ages ranging from 15 to 41, distributed as: 1% IDU (2), 10% RFSW (7), 23% FSW (16) and 65% MSM (45). Infection with HIV and syphilis varied in the sites. Laoag, Santiago, Surigao, and Tuguegarao have no HIV cases and less than 1% syphilis rate. Baguio, Dr. Eric Tayag showing IEC materials on Valentine’s Day. Butuan, Angeles, Cagayan de Oro, General Santos, Iloilo, Puerto Galera, Puerto Princesa and Zamboanga have less than 1% HIV and syphilis prevalence. Metro Manila, Metro Cebu and Metro Davao have more than 1%.
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HIV and syphilis were high among FSWs. Infection among MSM in Metro Manila was highest. Among IDU, there were significant findings on HIV and syphilis; in one site, 95% had hepatitis C. In 2007, there was one HIV positive MARP per 1,000. In 2009, the rate increased fivefold -- 5 HIV positive MARPs per 1,000 or 1 in every 200. In the BED assays, or tests that help determine if the HIV infection is a recent one, 47% of all cases were very recently infected, specifically within the last five months. The results and comparisons in the last survey per MARP were as follows: IDUs-133 per 100,000 in 2007 to 209 per 100,000 in 2009; RFSW-68 to 234; FSW- 44 to 542, and MSM- 283 to 1,052. Overall, the increase in infection rate was from 100 in 2007 to 533 in 2009, translated into a total of 2,279 if population estimates are used. Dr. Tayag said that if this was the prevalence, “the effects will resonate in other aspects of disease control on the part of government”. It could be translated, thus, “for every PLHIV taking ARVs supported by the government, there would have been125 children vaccinated for measles, DPT, polio and BCG. The cost or investment for providing ARVs to 2,279 PLHIVs is equivalent to more than 250 children who will not be vaccinated”.
Tracking the Disease
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etecting HIV in the population has not always been an easy task. In a country where the disease has been described as growing low and slow, tracking it has been a challenge, as HIV is evolving and requires special techniques to track in specific groups. The DOH NEC was mandated to perform such functions. The NEC’s HIV/STI Sentinel Surveillance Unit was created in 1989 to develop and undertake the monitoring of the HIV situation in the country. Manned by a medical epidemiologist and a surveillance officer, the unit established surveillance systems to track the occurrence of HIV and other STIs in the country. There are three systems utilized to track the disease. The National AIDS Registry passively records confirmed HIV cases from the general population, trends the occurrence of HIV and reflects the demographic profile of cases. The Sentinel STI Etiologic Surveillance System (SSESS) measures the frequency of STIs seen at the social hygiene clinics and requires basic laboratory techniques to diagnose infections, most of which come from SHC clients involved in sex work. And then there’s the IHBSS that monitors the disease among MARPs.
The IHBSS has three methods. The Time-Location Sampling (TLS) method was done among the FSW and the MSM that involved deploying teams to cruising sites and establishments frequented by MARPs. The Respondent-Driven Sampling (RDS) method was conducted among the IDUs wherein an IDU, known as the seed, would recruit other IDUs into the study. The succeeding batches of IDUs would then be counted as the nth wave after the seed. The Simple Random Sampling (SRS) was conducted among the RFSW that employed a masterlist of RFSW where respondents were randomly selected. More than 400 people with data collection skills to interview and collect specimen from registered and freelance female sex workers, MSM, and IDU were fielded. Armed with 30-page questionnaires, they conducted interviews on HIV knowledge, sexual
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IDU are aged 12 to 54. In one site, a 12-year-old was the youngest and first-time injector; a second site had an 11-year-old. For the third site, the IDU are aged 12 to 42. The IDU exhibited risks like sharing needles, sex between males and sex between and among males, females and sex workers. Condom use was slightly high in the first site, which also had effective prevention coverage of up to 60%. Among the MARPs, the age at first penetrative sex varied. The IDU and MSM on average had their sex initiation at age 7; the FSWs at 8 and the RSFWs at 9. By the time they were all 18, they have experienced their first penetrative sex. The RSFWs maintained their healthseeking practices by regularly visiting the SHCs and maintained their attendance in HIV prevention meetings and received free condoms while the FSWs did not know that the clinics even existed. Among all MARPs, 60% received the condoms free. Registered and freelance female sex workers performed better than MSM in condom use in their last sexual encounter.
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Foreign consultants were tapped for the IHBSS: Lisa Johnston, a global expert on RDS, and Henry Fischer Raymond, assistant director of the HIV epidemiology section at the San Francisco Department of Public Health, who ensured the quality of data that would be generated. Innovations were introduced to make the study more valid. The process started with the interviewers asking potential respondents bluntly if they have ever had sex. A cascade of questions followed after an affirmative response. Several concerns were observed, such as asking MARPs upfront about their sexual engagements that proved intimidating to the respondent and the conservative interviewer. In a society where the sex trade is prohibited but not discreetly practiced, refusals and denials to such profession were issues to contend with. Almost all of the data collection activities were done at night and even up to the wee hours of the morning. The laboratory experts simply got used to being called blood-seeking vampires when the respondents were sent to them. Disasters and tragedies did not spare the teams. In Marikina, typhoon Ondoy simply washed away a bulk of filled-up questionnaires when it deluged the city health office. In Caloocan, a team waded through floods one night just so that the “show must go on”. For some, there were life-threatening experiences, such as the interviewers in Davao and Santiago cities who were ran over while crossing the street trying to catch up with a respondent, and fortunately only obtained bruises and got back to work after a few weeks. Hard work and dedication to the task abounded. In almost all sites, personal vehicles were used. Some tagged along with spouses or siblings as chaperone at night. At the end, there was triumph, and the results may be said to be truly reflective of the HIV situation among the MARPs.
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STIs are generally said to be biological markers of one’s vulnerability to HIV as they alter the protective covering of the genital tract. Thus, the prevalence is closely linked with the occurrence of HIV in the population.
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The SSESS monitors gonorrhea and some non-gonococcal infections, bacterial vaginosis, trichomoniasis, syphilis, genital herpes and genital warts from the SHCs. Done on a daily basis, it consists of data from clients who are mostly establishment entertainers. Specimens collected from these clients are subjected to routine laboratory techniques to identify infections. The clients are given medicines, most of which are free, once found positive for any of the diseases under surveillance. Tracking the Disease
V I H g n i Prevent n (BCC) work tio ica un m m co ge an ch r vio ha be ing In do , the Project among MARPs and vulnerable groups environment aimed at providing a suppor tive vironment. and locally suppor ted policy en sive services and
st provide comprehen It should be holistic, exhaustive, mu proper groups in good coordination with information; and enjoins all target rs, MSM, lar sub-groups such as sex worke authorities. Interventions for particu of the workers, who are the beneficiaries and, to a limited extent, migrant available looked at previous experiences and Project, are evolving. The Project GFR6 rventions from other countries. The evidence of proven effective inte l NGO ugh the LGUs with identified loca implements BCC intervention thro ugh the the NASPCP and the project thro or groups as partners. The role of administrative provide technical assistance and national NGO sub recipient is to programs that are sustainable. support in further developing BCC and ent against STI and HIV, how to use The condom as a protective instrum not delivering effective ser vices, but is where to access it are foremost in or MSM. ular supply for use by sex workers designed to be provided as a reg vides tegy, the ‘Popshop for MARPs’, pro The Project’s social marketing stra activities of pocket mechanism. Prevention access to condoms through an out g and peer education, roll out trainin include training of trainers for BCC e HIV volunteer peer educators to provid of LGUs’ peer educators, tapping reach rs, MSM, and migrant workers, out prevention education to sex worke . The GFR6 regular HIV prevention education ser vices and assisting the SHC in ning of ro and the HealthGov for the trai partnered with the USAID’s HealthP nt, AIDS ion program while GFR6 sub recipie trainers and rollout of peer educat out the project implementation. Society of the Philippines, carried
transmission
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behaviors, injecting drug use, and access to health services. The last part of the data collection process involved the extraction of blood specimens that were promptly sent to the SACCL for HIV and syphilis testing, and for some sites, chlamydia.
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Preparing for the Unknown A
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lthough Santiago City has yet to record its first HIV case, it has started a prevention program supported by baseline data from rapid assessment surveys that surfaced the city’s needs, conducted through the DOH-GFR6 HIV Project. If the adage, “Two heads are better than one” is helpful to the city preparing for the unknown, Dr. Genaro Manalo, city health officer, explained that “teamwork is a result of sincerity and hard work that ensures a positive response.” Dr. Manalo led the multisectoral initiative using different strategies and collaborative linkages in STI, HIV and AIDS education. “There are no easy jobs, but through hard work, everything is possible.” he said. The city’s health workers mounted the advocacy for HIV prevention, supported by schools, police enforcers, people’s organizations, and public and private hospitals through a consultative approach and with the active participation of the city government.
The city took its strength from peer educators. Dr. Alex Armedilla, the peer educators’ mentor, said mentoring sessions have formed part of the peer educators’ monthly and quarterly meetings that discuss reports and plans to motivate them to do better. A schedule of activities was kept handy to keep track of activities, such as weekly Friday meetings to update programs and implementation. Perla Bautista, STI, HIV and AIDS coordinator in charge of advocacy and peer education, ensured that reports were submitted on time. “Report writing and submission have to be scheduled to avoid backlogs”. Dr. Robelyn de Vera Go, social hygiene clinic physician, said, “Valuing time prevents stress and teaches young partners like peer educators to do the same”. The city also adopted “bonding” as an important activity for the staff to relax and get together at least once a month.
Dr. Manalo said other public servants have yet to be convinced of the program’s benefits,
Santiago City Mayor Amelita Navarro signing up to the 10,000 signatures
but this should not weaken efforts and instead inspire more dedication to the advocacy. “Always take the initiative”, he said. It is also difficult to encourage people to do VCT because they are not yet fully aware of its importance to their health. More members should join the AIDS and blood councils. Sincerity, hard work and teamwork are continuous commitments. Peer educators will continue to reach out to their peers even without stipend. City health officers were tasked to be more vigilant in promoting the AIDS council. Candles of commitment
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Elevating the advocacy on STI, HIV and AIDS was one of the most challenging tasks of the city health office (CHO), institutionalized through a concerted effort of sectors including the political leadership. City Mayor Amelita Navarro was convinced by the hard work that she approved an executive order creating the Santiago City AIDS Council and issued an amendment adding more members for it to perform its functions effectively. Barangay health workers helped distribute information materials and conduct basic HIV and AIDS education. Peer educators and establishments worked with the CHO to reach out to more MARPs. Innovative awareness strategies engaged target groups such as the Gays Nite Out that provided HIV education. The Red Cross conducted mobile blood-letting activities in partnership with the Local Blood Council.
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Locals and visitors attend a film showing on HIV
Their next stop was the Mother of Perpetual Help Parish youth ministry where they conducted LGS with young people aged 10 to 24 about STI and HIV prevention, integrating the topic of premarital sex. Considering the audience’s religious affiliations, the educators opted not to talk about condom use as a method of prevention but emphasized abstinence and risk avoidance or abstaining from sexual intercourse until one is married, and to be faithful to a partner and knowing each other’s HIV status. The team provided a holistic approach through biblical perspectives and incorporated games.
Promise and Advocacy for the Common Good towards a Unique and Healthy Society, now duly accredited as a people’s organization by the region’s Department of Labor and Employment. Their efforts were acknowledged by the Caraga Center for Health and Development that invited them to speak in the regional consultative workshop in Surigao City. The DOH Caraga paid all their expenses, the very first time the tandem received a stipend for an event. They were later invited to attend a series of HIV and AIDS workshops in Manila and Cebu.
After the holding of the AIDS Candlelight Memorial in May 2008, the barangay council, barangay health care workers and purok officials held a community dialogue where they responded to sample questionnaires that determined their level of HIV awareness. The local officials gave plans of action in
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L
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ike Santiago City, Butuan City has yet to record its first HIV case, but it has planned for the eventuality. The City Health Office has engaged peer educators like Michael and Anthony who became advocates through a search for volunteer peer educators mounted by STI/HIV coordinator Erlinda Milloria who called on all MSM who are active in the community to join the three-day Peer Educators Training and Workshop. The team immediately immersed in a series of activities, the first through film shows at the Butuan Rizal Park, a cruising site of freelance sex workers and MSM, and at the barangay session, attended by the community, including
foreigners and visitors from other localities of Butuan and Agusan. After personnel of the Police Regional Office at the Camp Rafael Rodriguez expressed interest with the film, the team conducted a learning group session (LGS) at the Radio and Telecommunication Division to raise HIV awareness among policemen.
preparation for the eventuality of a person living with HIV in the community. Michael and Anthony resolved to visit the city’s 86 barangays to conduct more learning group sessions and film showing to reach the target population of 45 individuals, especially the MSM, per month. Because the educators started the activities without financial resources, they lobbied for support from the barangays and tied up with the vice mayor’s office. They also set nightly outreach education to all MSM in streets, terminals, funeral parlors, chapel, bars, pageants and disco events. To be identified better in the community, the team named the group “AGUS”, a Visayan word meaning flow of water, because it is a journey towards the fullness of life. “AGUS” stands for A
Additional support came from the Pangkalambuan Inc., a people’s organization, which set up a partnership for HIV and AIDS advocacy and funded informative tarpaulins. The Overseas Workers Welfare Administration also invited the educators as resource speakers in the pre-departure orientation seminars of overseas workers. This will be made operational by the regional office of the Philippine Overseas Employment Administration in the first quarter of 2010. They continued to do symposiums in schools and in the community.
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Setting up a peer education program
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E
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ricka, a college-age gay student, did not have Bonding with peer educators any idea what training was like, until he was invited by Santiago City health officers doing outreach activities on HIV prevention. The training was an unforgettable experience. Ericka was just a wayward young person who indulged in smoking, drinking and sex, often excessively. “I thought I was safe, I was good at what I was doing, but a big development happened to me”, he said. The training taught him knowledge on HIV and AIDS and behavior change that made him address his own personal overindulgences. He learned that drinking would put him in unsafe situations. “I’m flattered about my participation as a peer ed. I feel that I’m able to save lives and I feel that I belong”, he said. He also appreciated the gratefulness of people who thank him for sharing what he has learned. Robert, Ericka’s friend, is a 19-year-old college student leader and active theater member, had the same transformation after he attended a symposium in one of the city’s colleges. “The experience was overwhelming”, he exclaimed. “I felt the urgency to take action and stop the spread of HIV”, he added. He volunteered to work with the peer educators and the CHO to promote HIV advocacy. Robert’s active involvement redefined his perception of life and made him realize that as a young homosexual male, he was exhibiting risky sexual behavior. “I needed to do something to my risky behavior because my life matters to me”, he said. Robert now advocates for the importance of being responsible to one’s body, something that he does personally, and being more cautious with his actions. “I won’t stop advocating and I won’t stop learning”.
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Protecting oneself to protect peers
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aximo, a day care teacher in General Santos City who identifies himself as gay, feared that his sexual orientation would always put off people, even his coworkers, until he felt compelled one day to join a HIV Orientation day orientation because the invitation was for MSM. He wanted to clear his mind. “People know I’m gay but they don’t know that I have sexual relationships with other men”, he said. The orientation day was his turning point. Information on STI and HIV overwhelmed him. “It was a wake up call. I realized that my unsafe sexual practices could mess me up; the worst that could happen is that I
may die of AIDS complications”, he said. Maximo considered the event a blessing. “It taught me how to be in control of my sexual desires, and that I should be more cautious with my partners.” In his own little way, he stressed that, “I must do something to prevent the spread of HIV infection”. He was later officially taken in as part of the City Health Office team that will promote HIV prevention.
A calling
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eer educator Anthony of the Butuan City Health Office is an active member of a group that does pageants, dances and theater arts, and the parish youth ministry. In February 2009, he added HIV prevention among his advocacies when he joined the training on HIV and AIDS. A sexually active male homosexual, Anthony said the knowledge he received from the training was worthy. “It was something that money can’t buy”. He became one of the advocates with other peer eds who plan and implement HIV prevention activities. Anthony handled more responsibilities beyond HIV advocacy, representing the youth in various CHO leadership trainings such as the “Volunteer Youth Leaders for Health in the Philippines” that tackled newborn screening, birth defects and folic acid campaign. His 10month experience with the Project motivated him to educate more and encourage the young to respond and be part of HIV prevention efforts. “I accept challenges, because the trust that was given to me is a calling from heaven”, he said.
Organizing the party
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moking, drinking, cross-dressing, and sexual activity were typical of Melvin’s years as an out of school young gay with an aimless life. His life-changing moment began when the focal person of the Santiago City Health Office (CHO) invited him to the training on HIV and AIDS. He found it tough. “My reaction on the first day of training was, ‘What is this? What should I write in the test paper? I’ve no idea about HIV. Is it right that I’m here?’, and it was really terrible because I didn’t know the answers”. But after the training, “I felt different”, he said. He went back to school to have a better direction in life. He played a major part in the planning of the Gays Night Out Loud project, a get together party for the gay community in Santiago as part of the innovative strategies of the CHO in reaching out to a risk group using an alternative approach through music, dance, drama, and STI, HIV and AIDS education. It was followed by a bigger party inviting gays from nearby towns where the CHO provided voluntary counseling and testing (VCT). The gays were responsive to STI, HIV and AIDS issues. “Some of them became emotional during the orientation; some were shocked at the visual presentation and most importantly, all of us underwent VCT,” said Melvin. ”I have lots of memorable stories. I feel grateful to realize that there are many ways to help people.”
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Passing on the message
ffecting change through peer education
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of STI and HIV considering the mobility of the FSWs in the highly urbanized city that is the center of trade and commerce in the Autonomous Region of Muslim Mindanao and the Zamboanga Peninsula. Cognizant of the need to help risk groups and the unregistered, city health officer Dr. Rodelin Agbulos conceived the mobile clinic in 2008. It offered services such as smearing, counseling, treatment, STI-HIV evaluation, condom and information materials distribution and on site film showing. Dr. Uddin leads the health team that includes a nurse, STI coordinator, outreach workers and trained peer educators.
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he plaza has been Mr. Clean’s workplace as a pimp, and his abode when he earned little or nothing. Today, Mr. Clean is a fixture in the area, though in a different capacity, scouring hidden corners to find FSWs and MSM, then drive them to the mobile van stationed at the plaza on Tuesdays. As a peer educator of the city’s Reproductive Health and Wellness Center, Mr. Clean is credited for his work in Plaza Pershing and in the City Health Office’s (CHO) efforts to monitor vulnerable groups. Dr. Kibtiya Uddin, the center’s head physician, credits Mr. Clean as the driving force behind the clinic’s success. “He has contributed much in referrals. Through his great effort,
other FSWs who submitted themselves for smearing are now regular clients of the clinic”, she said. Mr. Clean knows the place. “I have established rapport with the FSWs and I have gained their trust as I never cheated with money as a pimp”, he stated. From what he learned as peer educator, “I convinced them to avail themselves of the center’s services. I believe they seek the services of the clinic because they have been educated about the risks of their work”. The Zamboanga CHO values the clinic’s contribution to the prevention and control
&
Mr. Clean the freelancers s t ep s o u t p a c in g t h e e p i d e mi c
Mr. Clean and Plaza Pershing are inseparable figures among sex workers and MSM cruising one of Zamboanga City’s premier promenade.
The clinic tied up with the Task Force Buenas Monitoring Team, created through a local executive order that is the monitoring team of the Zamboanga City Multisectoral AIDS Council composed of the RHWC physician and sanitary inspector, city administrator, city treasurer and the police. The team reaches out and delivers services to prevent the spread of STI, HIV and AIDS and complements the clinic’s efforts
by undertaking regular monitoring in establishments when the clinic is in another site. The center and the police render the clinic fully functional, creditable, and trusted. In 2009, the Project capacitated the clinic to reach more MARPS. The Human Development and Empowerment Services (HDES) supplemented the initiatives of the CHO in improving HIV awareness and promoting the services of the RHWC to MARPs. For the mobile van, the project provided additional equipment, supported fuel and snacks of the health team during late night operations, and the services of a HDES-trained and committed peer educator.
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OFW forum
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can be vulnerable to HIV
In Angeles City, a forum for OFWs was conducted in 13 out of the city’s 33 barangays from May to November 2009, attended by 502 OFWs including their families and relatives. Barangay officials, midwives and barangay health workers helped in coordinating the forum, which provided a situation report of STI and HIV in Angeles City, basic facts and signs and symptoms of STIs, modes of HIV transmission, condom demonstration, and the promotion of voluntary counseling and testing. Majority of the participants expressed gratefulness for their increased awareness and committed to re-echo what they have learned. It was also noted that the community of suspected tuberculosis patients and pregnant women will undergo counseling and testing at the Reproductive Health and Wellness Center.
Breakthrough in backdoor migration Zamboanga City’s moniker as the Philippine archipelago’s “backdoor” has attached idiosyncrasies, from harboring a sea port for commerce and migration, to being a transit point of Filipinos and foreigners engaged in illegal and exploitative operations such as smuggling, barter trade, the so called “barter of the flesh,” and human trafficking mainly in neighboring countries Malaysia and Indonesia. Port activities may have contributed to the city’s prosperity but they also birthed the proliferation of entertainment establishments, making the city susceptible to STI, HIV and AIDS. Freelance female and male sex workers and MSM make a living in cruising sites and establishments. FSWs not regulated by the Reproductive Health and Wellness Center
for STI services face the highest risks, including those rescued from underground operations. In 2007, the City Health Office recorded 101 FLSWs, 66 MSM and 10 male sex workers. In the same year, the Integrated HIV Behavioral and Serologic Surveillance revealed a low score in consistent condom use and similarly low level of knowledge of HIV and AIDS (less than 50%) among respondents from this group. Being home to many deported Filipino migrant workers, Zamboanga also confronts the vulnerability of migrant workers to STI and HIV infection. Upon their return to the Philippines, these workers become unemployed and have scarce opportunities. They lack community assistance, social services and education, which compromises their reproductive and sexual health needs. Through the Project, the city government established the Backdoor Migration Project, an innovative program for migrant workers’ health care and welfare, with a core strategy of fully educating migrant workers of their rights and to be sexually responsible individuals. From June to November 2009, migrant desks were set up and maintained in different government agencies that deal with overseas Filipino workers (OFWs). Learning group sessions were also conducted weekly in five barangays and at the Processing Center for Displaced Persons where deportees were temporarily sheltered. The Human Development and Empowerment Services (HDES) was tapped to coordinate and implement activities by reaching out to returning migrant workers that include
deportees who needed to be fully informed and educated about STI and HIV and AIDS awareness and prevention. Support programs were through distribution of condoms and information materials including on-board video shows. Treatment, care and support were rendered through a referral system. As it is still in its early stage, the project’s available resources and means are limited in monitoring and evaluation of migrant workers. The HDES has proposed that a website should be established to continue the project so that more migrant workers will gain access to services or resources.
‘Halao’ Marlon used to work in Kota Kinabalu in the island of Sabah, south of Malaysia in 1992, but after failing to renew his passport, he ended up as a TNT or “tago nang tago”, a Filipino term for migrants who are forced to hide from authorities due to lack of proper documentation but still continue to live in the foreign country of their work. Marlon ended up in jail for a month after he was caught working in a club. After some time, Marlon was recruited by the HDES to help the halao, a term in the area’s native tongue for deported migrant workers. He became an effective advocate because of his vast experiences in cross-border situations.
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Migrant workers
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The HDES under the Project conducted training of peer educators and learning group sessions (LGS) at the Processing Center for Deportees and Displaced Persons (PDCP) to capture the attention of deported migrant workers and to provide the necessary and basic knowledge and social services through education.
The CHO strengthened efforts to raise awareness to larger populations due to the weak appreciation of OFWs on HIV and AIDS. More participatory approaches were formulated, such as challenging local governments to address critical gaps in public awareness by focusing not only on HIV education but in preventing stigma and discrimination. Information distribution that gathered positive feedback from the Anak OFWs challenged the SHC to organize an activity that explores skills in creating HIV posters and messages.
Preventing mother to child transmission of HIV When Sally (not her real name), a 42 year-old person living with HIV (PLHIV), was 30 and married to a Singaporean, she became pregnant and gave birth to a baby girl in the Philippines. While applying for permanent residency in Singapore, Sally and her baby had an HIV test in Manila in compliance with an application requirement. Both mother and child tested positive. There was no counseling done at that time since the Philippine AIDS Law has not yet been enacted. Her husband, who underwent the same test in Singapore, also turned out to be positive. The baby girl grew up without succumbing to opportunistic infections, but at the age of four, she developed and eventually died of TB meningitis. Opportunistic infections are infections caused by microorganisms that affect only those with weak immune systems such as PLHIV. At the time of Sally’s test and her baby’s death, antiretroviral (ARV) drugs, which are medications that can slow down the progression of HIV infection but neither eradicates the infection nor cures the disease, were not yet available for children. The AIDS Registry has recorded 49 cases of mother to child transmission from 1984 to November 2009. Although the number seems insignificant compared with other countries with high HIV prevalence, the impact of having an HIV positive child is indescribable. These children will most likely need to take ARVs for life. Aside from the cost of drugs, the s t ep s o u t p a c in g t h e e p i d e mi c
A migrant desk in every local government unit was one of the innovative strategies of the Project. In Davao City, the migrant desk was conceived as the LGU arm in providing basic HIV and AIDS education to migrant workers, and a mechanism to promote the services of the Reproductive Health and Wellness Center (RHWC) to migrants and their families. It would provide counseling services and referrals when necessary. The idea was to set it up as a corner in the Pre-Employment Service Office of the LGU to work in close coordination with the center. The Davao City Health Office, however, opted to install the desk at the wellness center on an integrative health service delivery approach, catering mainly to risk groups. But no migrant workers visited the center. The desk was set up with the collaboration of the Mindanao Migrant Center for Empowering Actions, Inc., an NGO that deals with migrant workers’ concerns. The collaboration reached out to communities to disseminate information on HIV and AIDS and provide protection to OFWs from
stigma and discrimination. A total of 508 people were provided with community education on heath, migration and HIV and AIDS: barangay officials, community leaders, OFW families, returnees, Anak OFWs, university students, professors, teachers, young people, and community settlers. Education materials were also distributed to OFWs and their families in other venues such as the University of Southeastern Philippines and barangays Sto. Nino and Mintal. They were also distributed to participants beyond the targeted groups, such as farmers, small land owners, community health workers, church workers, teachers, security guards, and vendors. The social hygiene clinic provided counseling and referrals to distressed OFW families and returnees.
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Prior to the implementation of the Project, most of the migrant workers like Marlon did not have any proper education and instruction on safe sex methods or practices or any form of community assistance. The LGS provided influence and quality service to the halao in basic knowledge with a follow-up evaluation in PCDP and their barangays after deportation. It proved to be an innovative strategy in the prevention of sexually transmitted infections and HIV. Due to some limitations, implementers are challenged by a big number of migrant workers to support, making the center no longer conducive to learning. There is also the problem of language difficulties and religious conflict, unstable peace in remote barangays, and difficulty in locating the halao because of their constant relapse or “fallback” into the same problem of getting deported due to financial problems or family needs. All these problems notwithstanding, the HDES continues to provide support.
Migrant Desks
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The DOH acknowledges the importance of instituting the prevention of mother to child transmission (PMTCT) strategies to ensure that no further HIV infection would occur on Filipino children. The department’s NASPCP has taken initiatives such as the issuance of a PMTCT national policy and development of training modules to establish PMTCT in the Philippines with technical and financial support from the DOH-GFR6 HIV Project and its sub-recipient, the Remedios AIDS Foundation. Other development partners and organizations also take part in establishing PMTCT by providing technical inputs and/or funding support to NASPCP. To institutionalize strategies at different levels of health care, the department issued a policy in the form of an administrative order in May 2009. This policy is anchored to the framework of the United Nations’ four pronged PMTCT strategies.
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This framework provides a wide spectrum of strategies from preventing transmission of HIV among women of reproductive age to provision of treatment, care and support to women living with HIV, children and their families. In order to put concrete actions into these strategies, different services are designed for each prong that health facilities can adapt based on their capacity. All these services are expected to be delivered by the treatment hubs or hospitals with a functional HIV/AIDS Core Team (HACT) that provides treatment, care and support to PLHIV. The treatment of opportunistic infections and the provision of ARVs can only be accessed in facilities.
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A training module was also developed to impart the right knowledge, skills and attitudes to health care providers nationwide. The first series of training was undertaken in September to October 2009 involving health care providers from treatment hubs, members of treatment, care and support NGOs and Centers for Health Development coordinators. Although there are still many things to do to sustain PMTCT services, the issuance of a national policy and the availability of training modules are already considered as big steps in preventing cases of mother to child transmission of HIV in the Philippines.
Preventing HIV through The STI control program is the comprehensive provision of diagnosis, treatment and appropriate counseling to all cases of STI.
Treatment for STI such as gonorrhea, syphilis and other bacterial STI is easy with the advent of more effective antibiotics, while for HIV, genita l warts and other STI caused by viruses offers no immediate cure at the mome nt. While medical advances have provided the clinical management aspect of the program, the biggest challenge is reaching people with STI and provid ing comprehensive care to those who seek services. The health seekin g behavior is low, and self medication, which leads to drug resistance, is high, and the reinfection is also high especially for most at risk populations. In the Philippines, the social hygiene clinic (SHC) is established in health departments of city governments that offer services for STI diagno sis, treatment and counseling mostly to entertainment establishment workers and groups vulnerable to STI. In many of these facilities, there are moves to expand services so as not to stigmatize the facilities and offer a comprehensive package of wellness. With the available infrastructur e, the main goal of the Project is to leverage resources for operations of SHCs to expand HIV prevention education and create better supportive policy enviro nment. GFR6 provides augmentation support for diagnostic reagents, STI drugs, clinic and laboratory equipment and capacity building for health care worke rs on comprehensive management of STI, support to 100% condom use program among establishments and condom programming though popsh op for MARP.
l o r t n o c I T S & condom use
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inconvenience of taking the medications everyday puts a toll to both caregiver and child. Either or both parents are HIV positive. The children will most likely be orphaned before they can fend for themselves. The children may also die due to opportunistic infections especially if appropriate treatment is not given.
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gents of change
B
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eing a physician in the community often demands more than just providing medical attention. In Novaliches, Quezon City, four doctors man the mobile clinic almost 24/7. The clinic, which began operating on August 2009, was set up within the Novaliches Lying-in Center compound along Quirino Highway. Dr. Monina Santos, physician of the Quezon City Social Hygiene Clinic in Project 7, conducts activities such as demonstrating how to use a condom to freelance female sex workers, smear testing and counselling in the mobile clinic. A smear test, an examination of a woman’s cervix, is a painless procedure that entails taking samples of both cervical and vaginal cells smeared onto a glass slide and analyzed under a microscope. Smears are important screening tests to determine the presence of infection, or abnormal cells that, if not detected and treated, may lead to cervical cancer. If left untreated, they may develop into severe sexually transmitted infections.
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Dr. Santos took charge of operations while Dr. Annie Innumerable of the Quezon City Social Hygiene Clinic headed the mobile clinic. The other physicians were Drs. Suzzette Encisa of Bernardo clinic and Dottie Mercado of Batasan Hills. Peer educator John Jardenil and his colleagues were instrumental in assessing the location and establishing the mobile clinic. The area’s being heavily populated and has never been served by agencies were considered in the choice of a venue to host the facility. The
clinic adjoins the plaza, one of the cruising sites of sex workers. Services are easily accessible in the evening. The physicians were accessible beyond their clinic hours. Outreach, surveillance, and identification of volunteers to reach the MARPs were strengthened. Freelance sex workers who lacked awareness about their risks were reached through training. Dr. Encisa credited the peer educators’ active involvement as helpful in letting the MARPs know that the facility exists and offers services. Good attitude, commitment and humor are indispensible in engaging the target populations. “If you don’t have these, I doubt if you will succeed in this endeavor”, Dr. Encisa noted. Free check-ups, condoms, and medicines entice the clients to return. They also avail themselves of the HIV pre- and post- test counseling because they consider these as important and give them a sense of relief and security that there is a safe hub that caters to their needs. Through the help of peer educators, the physicians were able to stress the importance of a regular check-up at least once a month and relied on a log book to check on the MARPs’ records and monitor their checkups. Regular clients keep track of their health status and seek medical help and have made them conscious of their health and sexual behavior. They confided that free condoms helped break their fear of acquiring STIs, HIV and AIDS.
Reaching out & expanding Prior to the DOH-GFR6 HIV Project, Angeles City has been operating a mobile outreach clinic for more than five years, primarily in the casa and establishment bases in the city’s barangay Sta. Teresita, servicing at least 60 FSW every week through the barangay outpost clinic with the help of peer educators, casa owners and managers. The services were given for free, including the clients’ medication. Pre and post test counseling, information and education campaign materials and condoms were also provided free to patients with STI and the clients and casa owners. The clinic is part of the continuing effort of the Angeles City AIDS Council in reaching the most at risk populations and to provide the necessary information, treatment and support to reduce and control STI and HIV cases in the city. The city government envisions an AIDS-free city that is the safest entertainment capital of the Philippines. When it started operations in July 2009 under the Project, the clinic provided education and counseling to 78 FSW and 90 MSM in the cruising sites along the streets. Out of 168 individuals who were examined, 18 were treated with non-gonococcal infection, six with Gonococcus and one with bacterial vaginosis. The activities were done with the help of pimps and peer educators at the site. The availability of the venue for smearing was not that crucial, as hotel owners and managers were supportive in providing hotel rooms for free in every smear schedule, with the goal of having their establishment considered as free of STIs, and to entice more customers. The hotels consider their participation as helpful for their businesses, and in promoting their hotels to new customers.
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A
Dr. Monina Santos giving an orientation
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t age 13, Rhea became a sex worker, doing the rounds of clubs in Metro Manila. “I didn’t have a choice. Engaging in prostitution was the easiest way to earn money”, she said. Rhea’s unfortunate venture into prostitution started when she got pregnant at 12 by a then 17-year-old boy who became her husband. She said she rarely used condoms during sexual contact with customers. “They didn’t like using condoms. I didn’t care about it too”, she muttered. “Somehow I feel lucky because I don’t have HIV.”
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Now 27 years old and no longer sought by customers due to younger faces, Rhea sought freelance sex work. She studied how freelancers negotiate with customers. Along the way, she met John Jardenil, coordinator of peer educators in Quezon City, who invited her to join a peer educators training. Now a peer educator, she feels that, “a part of me has changed. I regained my self-respect and I felt affection for others who are like me”. Her life-altering experience transformed her into an advocate of consistent condom use. She is currently promoting, “No condom, no sex” because she believes the prophylactic is the freelance sex workers’ only weapon apart from education to prevent STI and HIV.
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Striving to make a change
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t a young age, Eileen, was one of the favorite entertainers of male customers in the bar. In 2008, she met Dr. Eunice Herrera, the social hygiene clinic physician of
P
Choosing option C
aid sex is Edalyn’s bread and butter, but she makes sure she is also protected by adapting “a condom free for every big spending customer” as her selling point. Her need for money often forces her to have sex with customers even when she is not well. She learned about condom use when she attended peer education activities on STI, HIV and AIDS in Caloocan City in 2009, which included the ABCDEs: A for abstinence, B for being mutually faithful, C is for consistent use of condoms, D for ‘do not inject drugs’ and E for education. “I’m afraid of getting infected because HIV has no cure”, she said. It is not easy for her to quit, so she took option C. “I have customers who pay me well, but if they want to have sex with me without a condom, I stand by my option”, she said. “It is better to be safe than die of AIDS
complications”. Edalyn shares her knowledge on HIV and AIDS with her peers. She believed this is the purpose why she met the staff of the Caloocan City social hygiene clinic, which she visits for her checkup at least once a week.
Becoming part the common good
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nne found out about HIV and AIDS infections only on the day she attended an orientation on HIV and AIDS by the Pasay City social hygiene clinic in 2009. Anne, who is married, has been a freelance sex worker for years. “I learned how to use the condom when I attended the clinic’s peer education activities. My husband and I learned so much about HIV prevention”, she said. “The good thing about it is I was able to share something helpful with my peers”. She was happy that her chance of being part of the activity was good since she became attentive to her health. “The money I earn can’t cure HIV”, she said. She reminds other women like her to always use condom to prevent possible STIs and to visit the clinic regularly.
A peer educator in every establishment
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ebu City passed an ordinance mandating all entertainment establishments in the city to have their own peer educators. Besides entertainment establishments, the city also trained its peer educators to deal with the implications of HIV in the lives of migrant workers. It drew strength from activities with partner NGOs, such as tackling mandatory testing that violates people’s rights. The activities reiterated that migration does not make OFWs vulnerable to HIV but the conditions and situations in migration that make up the factors of HIV
vulnerability. Workshops also conducted the development of HIV responses. Through the Project, the City Health Department improved its information materials, acquired STI lab supplies such as STI drugs, condoms, reagents, slides, gloves, and masks, and conducted trainings on comprehensive STI management, VCT, and STI and HIV proficiency.
D
It could happen
aniela, 24, earns P30 per client and looks forward to having extra earnings by doing “extra service” depending on what the customer wants her to do. “It’s quite hard to earn more nowadays, there are younger girls coming in”. Daniela has a fiveyear-old child under the care of her mother in the province. In 2008, Daniela participated in the Training of Trainers for Behavior Change Communication by the Santiago City Health Office and social hygiene clinic. In the simulated exercises, she got hold of a paper marked HIV+. “I felt that this could happen to me,” she said. From that day on, she told her customers that even if they pay more but will not use a condom during sex, she will not provide extra service. If they don’t like it, she wouldn’t budge either. “I learned to consider myself my investment, so I must be careful always”. Daniela took personal responsibility to educate her co-workers. “I remind them to avoid getting infected by using condoms consistently”. She demonstrates to other girls the use of a condom by mouth. Although she has no control over their decisions, she is more than happy to note that they listen to her. She refers the girls to the clinic so that they will be conscious of their health. She distributed information materials during
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A
No condom, no sex
Puerto Princesa City when the clinic conducted VCT activities. “Eileen was very cooperative. She knew her risks of getting infected”, said Dr. Herrera. Eileen has become the clinic’s regular client since then, visiting the clinic every two weeks. “When she had an infection, we encouraged her to take her medications religiously and stop her sexual encounters”, the doctor said. Eileen chose to continue going out with customers but used condoms. However, she became pregnant. The clinic was challenged to treat her STI and protect her infant against any infections. Despite her pregnancy, she continued to go out with her customers to save money for her delivery, but she assured Dr. Herrera that she was aware of her baby’s health. “She came for check-up every week. We monitored her pregnancy until she gave birth to a healthy baby. Her STI was treated.” After two months, Eileen went back to the bar, wishing to earn more for her daughter. She is a regular client of the clinic, which has become her and her daughter’s second home.
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Daniela plans to go to school, but she has to save more money for her and her child’s needs. The Santiago CHO implements a complete package of services and basic support to entertainment establishment workers like her, such as opportunities to be included in skills training development sponsored by the city in collaboration with Technical Education and Skills Development Authority (TESDA).
Pushing for behavior change and social responsibility
C
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ondoms are the “popular choice.” This is the rallying cry of POPSHOP, a marketing strategy of DKT Philippines designed to meet the contraceptive product needs of the community. DKT is a non-profit organization that promotes family planning and HIV prevention. POPSHOP, a word derived from the information campaign to make condoms “a
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popular choice” and to make them accessible and affordable, offers and provides DKT products, operational training, material and promotional support, and management and technical assistance to franchisees. Under the Project, the franchisees are LGUs and NGOs with viable and immediate options to procure and distribute contraceptive products, with a cost-recovery mechanism built into the franchise that is designed to ensure sustainable operations. The institutionalization of POPSHOP in Puerto Galera began in February 2009 involving Puerto Galera Mayor Hubert Christopher Dolor, municipal health officer Dr. Ginalyn Caguete, Bong Yap, LGU officer of ASP, Maita Mabini, DKT regional franchise coordinator, and Joel Atienza and Mona Morales, the Project’s technical component manager and site implementation officer, who analyzed two major concerns: the setting-up of the POPSHOP business may affect the smooth partnership of the local government and faith-based organizations, for an obvious reason that it promotes a 100% condom use; and the role of the LGU that would go against government policy, as it would require selling a product. The group decided that the Galera Association of Managers and Entertainment
(GAME), an association of seven members, take the lead in the franchise without the local government’s involvement. When he accepted the franchise, GAME president Mr. Lopez believed that it will flourish in his community because it will not only generate sustainable income but protect against STI and HIV because condoms are sold at affordable prices and help promote a 100% condom use among entertainers and MSM. DKT and GAME agreed to the terms and conditions for the partnership. The association set up the POPSHOP in highly trafficked areas; planned to apportion earnings to the clinic, the GAME’s office needs and those of peer educators, and to HIV orientation activities; and establish a cooperative for emergency utilization by members. Two weeks into the POPSHOP operation, a P10,000-worth condom display was mounted at the stall managed by Mr. Lopez, who said it amazed people who are not used to seeing condoms being sold inside the mall, but shoppers still bought the condoms. On the part of entertainers, they agreed with the bar owners’ commitment to promote 100% condom use, buoyed up by a series of HIV orientations. Bar owners implemented a “strict compliance of condom use” -- their entertainers carry condoms if their customers want to take them out. They also sold condoms to MSM frequenting the bars. Peer educators conducted prevention activities. From April 2009 to January 2010, the GAME has utilized 24 boxes of condoms equivalent to 3,400 pieces. The bar owners orders every two months from DKT. Mabini said the GAME is the most successful POP SHOP franchisee so far among the five franchises under the Project. “They have a good track record in condom utilization since the association developed a policy to promote 100% condom use among entertainers”. Bar
owners continued to impart behavior change and social responsibility, although it could not happen overnight. Mabini explained it in another way: “The process is like creating a sculpture. The details in molding the structure are essential in obtaining the figure that you wish to see. It looks like a silhouette in the beginning. If you don’t have patience and focus from the start up to the end, it will not show good results.”
Organizing GAMEs Puerto Galera had a little help from Angeles City in organizing the association of bar and establishment owners when the local government invited Dr. Tess Esguerra of the Angeles City Social Hygiene Clinic to teach them the exact steps using the experiences of Angeles City in the entertainment industry: general assembly of establishment owners, followed by discussions on putting up an organization. If the bar owners agree to the benefits of being organized, as this could help their business and prevent and control STI among their sex workers and clients, forming groups like GAME would not be difficult.
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outreach activities. She was greatful to the CHO for taking care of her until she became a peer ed. Daniela is one of the 594 peer eds trained under the Project and is the president of the peer educators’ organization. Based in an establishment, she is not required to reach out to other sex workers outside her work.
A male model promoting condom use.
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Being the only municipality among the Project sites, Puerto Galera has characteristics similar to a city – a decadent life that promises to be better come night time, with the added call of the beach. And like any other city, it has its own vulnerabilities. The GFR6-supported rapid assessment survey led by Toti Uysingco and a team of epidemiologists from the DOH NEC found high vulnerabilities of sex workers, mostly freelancers, to STI and HIV, compounded by their lack of comprehensive understanding about protection. The beach town has a lean social hygiene clinic staff based in the barangay health station in Sabang that services registered female sex workers (RFSW) and offers screening services to entertainers of six big entertainment establishments within Sabang, including smearing of 100 RFSW per week.
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On the far end of the municipality is the White Beach, a pristine white sand beach popular with locals from Metro Manila and Southern Luzon. Access to the SHC in Sabang from White Beach is difficult, limiting the beach’s access to services. The municipal government wants to widen the reach of information and effectively carry out its HIV prevention services such as regulation of lewd shows, provision of STI screening, condom promotion and HIV
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counseling and testing to the risk groups and the public. Mayor Hubert Dolor believes it is the government’s duty to provide basic information on HIV prevention, and this is also the responsibility of each person. Drugs that treat persons with STI and condoms are not provided by the municipality but are sourced from private groups for sale to entertainers and clients. The program improved during the implementation of the Project. Dr. Ginalyn Caguete, the current MHO, said logistics, organization and outreach improved. “Two years ago, the speculums were very limited and we have to regulate the number of clients, but now we have more and we are more equipped”, she said, showing the microscope, autoclave, pipettors, and gram stain and test kits for HIV and syphilis provided by the Project. She said the clients can also wait in comfort for their turn to be examined because there are now new chairs and electric fans. The town’s entertainment industry is now organized. To ensure that the female sex workers avail themselves of health services, she worked with the establishment owners. “They quarreled and competed with each other, but now, they are better organized and are addressing the issue of HIV prevention in a more comprehensive manner”.
V I H g n i t n e Prev g n i r u s n e by rigorous HIV prevention is done through a nation campaign for voluntar y blood do h mass media among low risk populations througstyle among potential ting for a healthy life and public education, and advoca er with ing the blood units for HIV, togeth donors and most importantly, test ble infections. other blood transfusion-transmissi
blood and encourage Filipinos to make To drum up its benefits to health Republic ment enacted and implemented donation a way of life, the govern ntary vices Act of 1994 to promote volu Act 7719 or the National Blood Ser al vice facilities and establish a Nation blood donation, upgrade blood ser through rk. Its lead implementer, the DOH, Blood Transfusion Ser vices Netwo d with vices Program (NVBSP), collaborate the National Voluntary Blood Ser ating (PNRC), Philippine Blood Coordin the Philippine National Red Cross lders, (DepEd), LGUs and other stakeho Council, Department of Education the ed efficiency with the creation of and instituted changes for improv s. Community-based advocacy was Philippine National Blood Ser vice areas blood donors in urban and rural strengthened, targeting potential through community mobilization.
blood safety
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Confronting vulnerabilities
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he safety of blood and blood products starts with the recruitment and recall (at safe intervals) of voluntary, nonremunerated blood donors who are risk-free. Safety is ensured through clean conditions for blood collection, appropriate screening
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Training on blood bank procedures
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of donors, extensive testing, proper storage, and appropriate clinical use of transfusion. The most expensive aspect of blood banking is testing for infectious diseases; the most critical is collection of blood from healthy blood donors. The quality of blood sources determines the quality of blood products. Blood services centralized the testing of blood for infectious diseases and blood component processing to achieve efficiency and quality to improve blood collection and distribution of blood components. This liberates many
described by the World Health Organization, International Federation of Red Cross and Red Crescent Societies as voluntary nonremunerated blood donors (VNRBD) who: • •
hospital-based blood service facilities from the costs of testing and focuses their limited resources to the clinical aspects of blood transfusion and patient care.
•
For blood transfusion safety, blood is carefully tested to ensure that they are free of the five transfusion-transmissible infections (TTIs) Hepatitis B, Hepatitis C, HIV, syphilis and malaria. Testing is a big leap against HIV transmission and towards a safe source of blood. The Project is implemented in 23 blood service facilities, with six blood centers with centralized systems of testing blood units for infectious diseases, processing of blood components and improved blood collection and distribution systems.
Altruistic social responsibility The call for altruism is embodied in voluntary blood donation. People who heed this call are
Campaign for a noble cause The campaign for voluntary blood donation includes advocacy for healthy lifestyle and HIV prevention. To foster voluntary blood donation, the following WHO, Red Cross and Red Crescent strategies can be well adopted:
Blood safety donor recruitement workshop
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• •
• • • Lecture on organizing mobile blood donation
understand the importance of blood donation; are not under pressure from hospital staff, family members, or the community to donate blood; donate blood, plasma or cellular components of their own free will for altruistic reasons;
receive no payment for their donation, either in the form of cash or in kind which could be considered a substitute or incentive; receive no reward or incentive except personal satisfaction and self-esteem; have no reasons to withhold information about why they may be unsuitable to donate blood; have lower prevalence of TTIs than family/ replacement and paid donors; entrust their blood donations to be used as needed, rather than for specific patients; and more likely to donate on a regular basis.
• • • • • • • •
Understand your blood donors. Identify target donor populations. Develop communication strategies for donor education and community involvement. Build partnerships with the media. Mobilize community partners and create networks. Maximize the impact of World Blood Donor Day and National Blood Donor events. Educate, motivate, and recruit new blood donors. Mobilize youth as a new generation of voluntary blood donors.
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Convert eligible family/replacement donors to voluntary blood donors.
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Recall infrequent, inactive, and (temporarily) deferred blood donors. Retain suitable voluntary blood donors. Recognize blood donors’ contribution to society. Make it convenient for donors to give blood.
• • •
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HIV prevention through voluntary blood donation T
The VNRBD are deemed to be the safest sources of blood for transfusion. A global effort is continuously undertaken to encourage individuals to realize to uphold voluntary blood donation by sustaining adequate, safe blood supply and safe blood transfusion, which can cause a hundred percent transfer of infection if not given the highest quality of management right from the source.
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• • •
Reach out to donors through mobile donor sessions. Assess donors’ suitability to donate blood. Provide blood donor counseling; and Make blood donation a safe and pleasant experience.
With the Project’s assistance, advocacy was intensified through training and re-orientation of the facilities’ personnel on donor recruitment, retention, healthy lifestyle, HIV prevention, use of blood cold chain, blood bank procedures, total quality management, and blood donor selection and counseling with emphasis on self deferral, strengthening of referral systems, VCT and the HIV/AIDS Core Teams for confirmed HIV positive blood donors.
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Strengthening partnership
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The Blood Safety Component, in partnership with the DepEd and Philippine Society of Hematology and Blood Transfusion, developed learning materials on voluntary blood donation for the school curriculum of the Bureau of Elementary Education, Bureau of Secondary Education, and Bureau of Alternative Learning Systems. Education can play a major role in creating values that embrace altruism and community solidarity. Children can be given
Partnership with local government executives and health personnel in the cause of voluntary non-remunerated blood donation is the common ground of blood safety facilities, complemented by the collaboration with the academe, religious groups, business, youth, non-government organizations, and media. An active Local Blood Council helps sustain the chain of a Blood Services Network, making blood accessible and preventing wastage. In Southern Mindanao, the strong partnership between the Davao Blood Center, which has achieved a 100% voluntary blood donation, and its neighboring LGUs has consistently earned for the Center for Health DevelopmentSouthern Mindanao an award for the highest number of local government executive awardees during the National Sandugo Awards, conducted duirng Blood Donor’s Month in July. Similar efforts have also been demonstrated by the Cagayan Valley Medical Center and the PNRC-Western Visayas Regional Blood Center.
Objectives of Donor Information and Counseling: To maintain safety of blood supply and quality of blood products; Enable persons with high-risk behavior or have traveled to high-risk areas to defer themselves; Identify medications being taken by the blood donor that may affect the quality of the blood product; To protect the health of the donor; To fulfill ethical requirement.
Pre-Donation Counseling Pre-donation counseling enables the blood donor to assess her/his own level of risk, and suitability as donor. It also includes educating the blood donor on maintaining a healthy lifestyle, and on the prevention of transfusion-transmissible infections. During the pre-donation counseling, the blood donor is re-directed to VCT centers should he/she admit having high risk behavior or having been exposed to high risk persons. Source: Blood Donor Selection and Counseling Manual, 2009
Launch of blood safety learning materials
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•
information to understand the uses of blood and how it can save lives. Part of the advocacy to school children was the distribution of the story book “Duglit,” which won first prize in the 1994 Don Carlos Palanca Memorial Awards for Literature, short story for children category, Filipino division. It tells the importance of blood cells to a person’s life, which was discovered by “Duglit”, the youngest and perky red blood cell inside Mang Omeng’s body. The book details the donation process and its importance.
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15
I
n its bid to increase repeat and walk-in donations, the Cagayan Valley Medical Center (CVMC) organized the Share 15 Club, a strategy to increase donor recruitment, repeat donation and retention and to address the regular loss of donors from the donor pool.
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Barangay lecture on mobile blood donation
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Share 15’s donors will pledge to donate blood at least 15 times until they become 60, hence, the name Share 15. They are recruited from the bank’s pool of repeat donors. Low risk individuals are recruited and first-time donors are encouraged to become repeat donors. Share 15 will be initially composed of a core group of 20 individuals; mostly paramedical professionals. Aside from being regular donors, they will recruit at least five new members who will also pledge to donate at least 15 times and recruit five more new members each. This will eventually gain an increasing number of regularly donating blood donors. The four
Club T
level membership starts with registration and donation as Level 1 (yellow), enters Level 2 (green) after recruiting five new members, Level 3 (blue) after recruiting five new members each. Level 4 (red), the highest, is attained after the member has donated 15 times. Continuing education on blood donation, donor recruitment, and selection will be part of the activities through lectures, workshops, and information materials. It is the prerogative of the member to determine the frequency of donations, though three to four months is preferred. A member who is not qualified due to temporary deferral reasons can only continue donating once the deferral duration has lapsed. For permanent deferrals, the member will be required to recruit five donors to enter Level 2. The number of donations that the member lacks upon being permanently deferred will be converted into recruits to enter Level 4. Members who resign for some reasons may do so voluntarily, provided they inform the club through a resignation letter and the reason for such so it can improve the organization.
Cagayan Valley Medical Center staff
Blood
he PNRC-Western Visayas Regional Blood Center yearly conducts the Blood Olympics, an event designed for multiple groups, companies and schools who wish to conduct mobile blood donation (MBD). The event aims to increase awareness for voluntary blood donation for these groups to recruit more and increase blood collection. Done in one or two days, the event is more enjoyable than the usual blood donation activity. Mechanics 1. Identify the organizations or sponsors. 2. Contact the local PNRC blood center. 3. Recruit and identify potential blood donorss who should be registered into three teams or more: (e.g. Blue team, green team, yellow team, pink team, etc.). The donors should know their team. 4. Identify potential blood donors involved in each team and arrange a series of meetings (at least thrice) from the identified groups. 5. Submit a letter of request to arrange MBD schedule. The date should be when almost all of the potential donors are available, preferably in the morning, and in a convenient venue with good ventilation and proper lighting. 6. There will be a pre-registration to determine registered blood donors’ weight and vital signs, after which the donors undergo proper selection and screening by authorized PNRC staff.
Olympics 7. Blood donors on each team will be given a card that corresponds to the color of their team, and they will carry the cards up to the physical examination by the PNRC physician on duty. The card will reflect whether the blood donor is accepted or deferred. This card contains the following data: Team: Address: Age: Accepted: Reason for defferal:
Name: Weight: Blood pressure: Deferred: Points earned:
8. Points will be earned by each team. Donors who were identified, accepted and have donated blood will earn 100 points while those who registered but deferred will earn 25 points. 9. Earned points are duly awarded to the participating teams. 10. The winning team will be recognized right after the Blood Olympics program. 11. Target number of donors: 100 - 300 12. Snacks for blood donors and meals for PNRC staff will be shouldered by the sponsoring group. 13. PNRC will issue blood donation cards as a record of donation and blood typing. 14. PNRC will provide a sample referral form, to be given by the organizer to their constituents to have an idea in the process of blood request. 15. For further information, please call (033) 3372359/3372088 and look for Dr. Judith S. Jimeno (PNRC-WVBRC Blood Center Manager) or Ms. Leanne Ferrer, RN.
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The Share
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for
started to disseminate what he learned and the information imparted by the donor recruitment officer of the blood center that conducted a mobile blood donation. To live healthy lifestyle, he said, is essential to blood donation. As a galloner, he received a Pearl Award corresponding to the frequency of his donation. The glimmering plaque inspired him to be dedicated to this advocacy. “I will donate more and encourage more people to be part of voluntary blood donation. No service is greater than helping a fellow man in the most altruistic manner”, he said.
How is it like being a Muslim working in a HIV Project?
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rior to my assignment in the Project, I was in a dilemma between accepting a job offer abroad and working in the country. I chose to stay. During the interview, I was tearful as a Muslim being considered for the job. I would be happy to just make it to the shortlist. Like other Muslims, I feel the discrimination around, not necessarily on me but on friends who are discriminated on for being Muslims. One of the interviewers asked if I could work without my veil on. I said I wouldn’t trade my culture and religious belief over a job that would make me remove my veil. I was thankful for the question because I knew they wanted to learn more about cultural diversity. I was also grateful to my superiors and colleagues who recognized my efforts, for
somehow, working with them brought peacebuilding efforts enveloped in a health proviso. I was assigned to the Project’s Blood Safety Component. I learned a lot about voluntary non-remunerated blood donation, blood transfusion safety, and the global advocacy on HIV prevention. A site visit to Angeles City stood out among my experiences. I got the chance to join the team to the social hygiene clinic. I was struck by what I saw – women in skimpy clothes and painted faces, and a row of speculums for their health examination. The Project’s technical component manager Joel Atienza teased me when he saw my appalled expression. “Nagulat ka ‘no? (Surprised?),” he said. From there, I learned how one of the
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ne unit of blood can benefit not only one patient but two or three. Knowing abut this value of blood matters so much to Andy, a voluntary blood donor and galloner, having donated nine times in threemonth intervals. He believes it is his social responsibility to share blood to help people survive a threatening illness or an accident. Because of component processing, in which the packed red blood cell or the platelet from the blood unit he shared may be transfused to one or two different patients makes Andy feel better. ‘It is better to give than to receive may be a cliché’ but it applies to him, so he
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In my pursuit of understanding this problem, I came across the Thailand-based Asian Muslim Action Network, which had been a pillar in the persuasion of the role of religion in responding to HIV and AIDS. In its October 2006 publication, “Responding to HIV and AIDS: Islamic Resources and Muslim Participation in Asia,” it cited the following faith-based resources and inspiration for HIV prevention and response. Teachings in Islam strictly prohibit premarital and extramarital sexual relations and reject all forms of sexual immodesty. As such, the Qur’an states:
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“Say to the believing men that they cast down their gaze (from looking at forbidden things), and guard their sexual organs (from illegal sexual acts, etc.); that is purer for them. Surely Allah is aware of what they do. And say to the believing women that they cast down their gaze (from looking at forbidden things) and guard their sexual organs (from illegal sexual acts, etc.) and not to show off their adornment…” (Surah An-Nur 24:30-3I)
“Nor come nigh to adultery, for it is an indecent and an evil way” (Surah Al Isra 17:32) “We made everything on the earth adornment for it, so that We may test them to see whose actions are the best” (Surah Al-Kahf 18:7) “So compete with each other in doing good. Every one of you will return to Allah about which you differed” (Surah Al-Ma’idah 5: 40) “Verily Allah will not change the conditions of the people as long as they do not change the state themselves” (Surah Ar Ra’du 13:11) Challenges occur in the awareness campaign and emerging responses to HIV and AIDS among Muslim communities worldwide, but in the global fight to help decrease infections, faith-based initiatives remain as the popular approach among Muslim communities. I know I wouldn’t be able to deliver certain tasks with self reservation of being a Muslim woman in a veil. Infection may not have a major impact or lower prevalence in Muslim communities, but I am more aware that HIV knows no periphery. I am convinced to learn more about HIV issues to be able to help in the awareness campaign both in Muslim and non-Muslim communities, and be even more ready in addressing this global problem. I asked at the start of this article how a Muslim like me feels about working in a HIV project. My second question would be, how would it be like helping a person living with HIV?
Anna Leah Dilangalen Dipatuan, MPA, is a Muslim and one of the site implementation officers of the DOH-GFR6 HIV Project, specifically under the Blood Safety Component.
Expanding voluntary As a general rule, screening people and doing nothing afterwards is unethical.
This was the predicament of the NASPCP when life saving ARVs were not yet available in the country. The Philippines has policy guidelines under the AIDS Law that specifies the requirements for a confidential and voluntary HIV testing by a competent facility. There are more than 500 clinics nationwide that offer quality assured HIV testing but the absence of inappropriate counseling was always lacking in the services provided to newly diagnosed PLHIV. Through the Project’s support, identified health facilities were re-capacitated on VCT, more so with counseling micro-skills l and the process to ensure holistic client care with adequate referra systems. The government’s thrust to provide ARV in strategically located treatment hubs provided more basis to enhance the demand for HIV counseling and testing. The Project was able to support the establishment of 18 SHCs and 14 hospital-based VCT centers in 16 LGU project sites.
counseling & testing
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Project’s interventions is carried out. There are many activities that I have not yet seen and would never be engaged in, but I have started a comprehensive knowledge search about HIV and AIDS. I know that it is perilous to millions of lives, including those of my fellow Muslims. In the Philippines, HIV and AIDS is a discrete issue among Muslims. Perhaps not a single Muslim has been infected to date, or there may already be, but they are not known within the community for fear of outward consequences. I think that faith-based teachings such as Islamic doctrines are still the most effective way to prevent HIV infection when coupled with scientific intervention.
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Manila Mayor Alfredo Lim campaigning for HIV prevention during World AIDS Day
Dr. Mendoza could only offer her thoughts about why the clinic was transformed into a safe environment for persons who seek confidential examination and HIV test. “The clinic is strategically located and discreet. It’s not within the city hall where people might feel ashamed to be seen lining up to be treated medically”, she explained. The clinic is also a stone’s throw away from the San Lazaro Hospital that houses the STD/AIDS Cooperative Central Laboratory (SACCL) that collects and confirms HIV tests submitted by all hospitals and clinics around the country and are officially recorded in the DOH AIDS Registry. Counseling is provided to individuals seeking health services, especially persons who think they are at risk of infection. The facility also extends services to applicants lining up for health certificates, even if they are not seeking HIV tests, so that they can receive and be guided by HIV information.
Service beyond women entertainers
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hen the Manila Social Hygiene Clinic (SHC) diagnosed its first HIV patient in March 2006, it was ushered into the world of HIV and AIDS. The facility has come a long way since its establishment as the first social hygiene clinic in the Philippines in the 1950s. “We’ve heard about HIV and AIDS, but since we have operated as a clinic for case finding and treatment of sexually transmitted infections (STIs), it was something new to us”, said head physician Dr. Diana Mendoza, who explained that the clinic has functioned as a health service facility not a regulatory clinic since the registration of entertainers stopped in 1995 at the closure of entertainment establishments in Ermita, Manila.
The transformation
With the emergence of HIV, the clinic, located in an unassuming urban quarter along Quiricada St. in Sta. Cruz, Manila, witnessed changes in its clientele in the years following its first HIV case -- from female sex workers to predominantly young men, mostly students and professionals. But before the throng of young people came daily to line up for HIV tests, the small staff of two doctors and two nurses took all measures to capacitate themselves by undergoing training on HIV and AIDS, specifically on testing and counseling that they found useful in counseling and character values. “We applied what we have learned”, said Dr. Mendoza. Currently, the clinic has three nurses and at least seven peer educators and has expanded its program to the
For its growing clientele, the clinic received support from international agencies and concerned organizations such as the United Nations Children’s Fund, which in 2006 added HIV prevention, including the provision of rapid testing kits, to its support to the facility under the 6th Country Program for Children. In
2008, the Good People International, a Koreabased organization, donated rapid HIV test kits. A rapid HIV test is also a HIV antibody test usually available in about five to 30 minutes. It is a single-use test that does not require laboratory facilities or highly trained staff and it can be done in one visit that already includes counseling. Dr. Mendoza said the counseling services and the clinic’s offer of rapid HIV tests are helpful. Prior to the availability of free rapid tests, an HIV antibody test would cost from P500 to P1,200. The cheapest confirmatory test at the SACCL would cost P300. The clinic had its first taste of publicity in 2008 when it was featured in a newspaper article, followed by a feature in a TV program. News about the clinic and its services increased among Internet users, until it became a buzzword among young bloggers. In December 2007, it officially became one of the sentinel sites of the Project. It provided services for STIs, voluntary counseling and testing, laboratory examinations and referrals, and developed institutional capacity through training and infrastructure, helped establish a local AIDS plans and ordinances, set up multisectoral coordination with PLHIV communities and NGOs, and harmonized resources and efforts. At the community level, it organized peer education training for MARPs, and literacy training for PLHIV. The clinic continues to receive a huge number of clients queuing up for counseling and HIV testing.
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prevention of STI complications and reducing HIV infection and its impact.
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Service with confidentiality and care
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aji never ventured into the low-key neighborhood of the Manila SHC, but he learned about the clinic and its free rapid HIV test through the Internet where a young HIV-infected blogger shared his experience at the clinic in his blog site. The 23-year-old, who said he is gay and has a regular sex partner, had his blood tested for HIV, and he turned out to be HIV-positive. “I was so afraid, but I took comfort in the counseling from the medical staff”, he said. “The nurse treated me like I was a friend in need”. He further praised the confidentiality and clarity of the counseling. “I was not treated as another statistic. I was never judged for who I was. I was informed and comforted”. In 2008, the clinic experienced a record-high 33 of its clients who tested positive in the rapid tests. In a period of only eight months between March to October 2009, 57 tested positive. Those newly infected were FSW and
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ore than 20 years after the first HIV infections were reported in the Philippines, medical professionals are still not comfortable when dealing with HIV infection. A 2003 study revealed that the highest rate of stigma and misinformation on HIV and AIDS was found among health workers. Handling a person who seeks answers to questions about HIV and AIDS and who faces the unknown in undergoing an HIV test remains a challenge. But not until VCT was conceptualized. VCT involves pre-test counseling provided before the HIV test, and post-test counseling following the HIV test when the results are given. The counseling sessions focus on HIV infection, AIDS as a disease, the test, and positive behavior change. VCT is helpful for people who want to learn about their HIV status and what to do about their condition. They can have access to a network of medical, psychosocial, emotional, spiritual, legal, and palliative services.
Through VCT, the Project sought to reduce the impact of HIV and AIDS among PLHIV and their families and friends. VCT increases the proportion of populations with risk free practices and access of PLHIV to quality information, treatment, care and support services. It helps improve the accepting attitudes towards people infected and affected with HIV and AIDS and the efficiency and quality of management systems that support programs and services. VCT is crucial in empowering individuals, changing attitudes and behaviors, reducing stigma and discrimination, and accessing HIV services, including safe blood units. The project aims to increase access of MARPs and the general population to VCT. The Philippine AIDS Law provides for confidential VCT, which is offered by DOHaccredited hospitals and licensed laboratories and clinics. Anyone with risks through unprotected sex with multiple partners, with persons of unknown HIV status, and injecting prohibited drugs should seek VCT.
Assurance of confidentiality
HIV prevention
The Philippine AIDS Law or Republic Act 8504, also known as the Philippine AIDS Prevention and Control Act of 1998, provides for confidential and anonymous counseling and testing under the following provisions: Article 1. SECTION 18. Anonymous HIV Testing. The State shall provide a mechanism for anonymous HIV testing and shall guarantee anonymity and medical confidentiality in the conduct of such test. ARTICLE VI. SECTION 30. Medical Confidentiality - All health professionals, medical instructions, workers, employers, recruitment agencies, insurance companies, data encoders, and other custodians of any medical record, file, data, or test results are directed to strictly observe confidentiality in the handling of all medical information, particularly the identity and status of persons with HIV. The said articles give the clients the strong will to submit for Voluntary Counseling and Testing (VCT).
MSM aged 15 to 24. In the first 14 days of January 2010 alone, 10 clients tested positive. The leap in infections in a short period among young people bothered the clinic’s partner peer educators. “It is alarming. We realized that young people are at the center of the HIV epidemic in vulnerability, rates of infection and impact”, said Ryan Pinili, the peer eds’ focal person. The clinic continued to build interventions tailored to meet the individual characteristics of patients and enjoined them to help in HIV prevention. With the help of NGOs and funding agencies, it improved counseling for risk populations by involving the peer eds on planning, organizing and training activities in partnership with barangay officials. Malou Tan, the clinic’s STI coordinator, said, “We want them to feel that they are not only part of the clinic but are part of the solution in preventing the spread of HIV”. The facility also engaged the peer eds in activities where they can explore their knowledge, skills and attitudes by giving them roles in the activities. They assisted and facilitated in giving basic information on HIV and AIDS. Tan said, “The peer to peer approach was very effective. They had fun while learning”. Tan said the clinic will continue its partnership with the peer educators and NGOs because their involvement widens the HIV network and learning opportunities.
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The pillar of
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Revelations
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utreach services making VCT available to MARPs is a crucial strategy for MSM and freelance sex workers as seen in the experience of the Manila SHC, which engaged peer educators and referral system for MARPs to access counseling to further link them to other support services. The RFSW are more organized and easily accessible while the opportunity for returning migrant workers needs further strengthening on how to ensure pre and post test counseling among testing done at OFW clinics. There is also a need to look into the financing of VCT for OFW as part of the PhilHealth package. While demand for the service is expected to make any new service to be sustainable, there is a need to ensure that the quality of services is optimal. The upcoming policy on HIV counseling and testing together with the regulatory guidelines will be the basis for evaluation of the quality of care. The GFR6 has enrolled VCT centers in the External Quality Assurance Program under the STI AIDS Central Cooperative Laboratory - National Reference Laboratory.
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nearby promotional booth, indicating that they could undergo free rapid HIV tests. The counseling and testing were provided by the Municipal Health Office of Puerto Galera headed by municipal health officer Dr. Ginalyn Caguete, along with her staff consisting of a nurse and a medical technologist. The campaign gathered 25 MSM who underwent counseling. In the HIV tests, five turned out to be HIV-positive. Nelson Yap, the LGU coordinator of ASP, said he was surprised at the results. “Our activity was a spur-of-the-moment thing, but it resulted in something as revealing as this,” he said. “We all wondered aloud about what we would have found out if we counseled and tested hundreds of MSM in the area at that time,” he exclaimed. Yap sad the revelation was more than an eye-opener, as much as a clarion call for an on-the-ground, stronger HIV prevention advocacy.
Dr. Gerard Belimac, (right) DOH NASPCP program manager, leads the launch of POPSHOP.
Linking with communities
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aoag City has an active linkage with the Don Mariano Marcos Memorial Medical Center that has a facility run by a trained HACT and was able to sustain its local program and linkages through the VCT center in Batac. The city held a forum on STI, HIV and VCT in August 2009 that discussed strengthening VCT because of the lack of peer educators for registered sex workers and MSM. The forum also took up the protection of persons living with HIV from not being identified in media reports, and tackled protection and counseling for minors and students working as sex workers.
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scorching, hot summer in April 2009 defined a turning point in the HIV and AIDS awareness campaign and the promotion of voluntary counseling and testing in Puerto Galera. The date fell on the year’s observance of Holy Week. But Puerto Galera being a dream destination, the place was overwhelming with young people, couples, sex workers, male gays, MSM) and individuals relaxing and searching for adventure. The Project headed by Dr. Gerard Belimac, program manager of the DOH NASPCP, ASP’s Nelson Yap and Ramil Esguerra, Efren Chan-Liongco of PNAC and Maita Mabini of DKT Philippines, were at the White Beach, Galera’s most popular hub, for monitoring activities, meeting up with the local government staff, and HIV advocacy. While the group distributed HIV education materials and saw that the crowd was dominated by MSM, they decided to include feelers inviting the MSM to undergo VCT at the
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hen I was confirmed HIV positive in January 2008, I thought that living with HIV was the worst thing that could happen to me. I was mistaken. It is living with HIV, not knowing that I have it, and not being equipped with the right information that was worse. I was one of the unfortunate who did not receive counseling, otherwise, it would have been easy for me to come to terms with my situation. I was referred to, and was tested in a small private clinic in Manila,
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which did not seem to have the capacity to conduct the required counseling. I did not know the importance and the need for counseling until I was referred by a friend to an infectious disease specialist in the Philippine General Hospital and met people from the AIDS Society of the Philippines, who unconditionally accepted me when I expressed my intentions to engage in their advocacy.
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With ASP’s guidance, I got involved with VCT workshops doing testimonials and as a resource speaker providing basic information about HIV and how it is like to live with the virus. In one VCT workshop attended mostly by doctors and health workers, a
participant approached me after I shared my story. She asked how a mild-mannered and decent-looking guy like me can be a PLHIV. I was humbled by her comments and realized that regardless of educational background, profession and stature in life, a person’s appearance is still being used as a basis in judging one’s HIV status. I felt assured that her participation in the VCT workshop would help her have a renewed perception towards people like me.
As I gained further understanding in the importance of counseling, in providing guidance to people getting tested for HIV and in the efforts to eliminate stigma and discrimination, and by involving my self in activities such as VCT workshops, I am confident that the workshop participants also gained the same awareness. This is one of the reasons why I have devoted myself to educational advocacy towards helping people understand HIV and how they can protect themselves and the people around them. We are all connected in ways we can only imagine. One person’s actions and decisions affect another person’s quality of life. VCT workshops are effective means of empowering people to make a positive change in other people’s lives.
Humphrey T. Gorriceta is the spokesperson for the National Association of Filipinos Living with HIV and AIDS and a volunteer for the Positive Action Foundation Philippines, Inc. and the AIDS Society of the Philippines.
Coming home to advocate for HIV prevention A
fter 14 years of working passionately in the field of HIV in New York City, I knew immediately that I wanted to share my experiences when I got back to the Philippines in October 2007. My involvement with HIV and AIDS work ranged from working in HIV and AIDS organizations and advocacy groups, including the world’s largest nonprofit organization that deals with HIV and AIDS. I came back to Manila and started to adapt to life in the Philippines once again. In the summer 2008, I went to the San Lazaro Hospital through my friend’s referral, and met Dr. Ann Joy Aguadera, a psychiatrist who provides psychosocial care to HIV patients, and Dr. Rosario Abrenica, head of the hospital’s HIV/AIDS Core Team and the H4 pavilion, the unit for hospitalized HIV patients. They toured me around the AIDS unit and discussed programs offered to HIV patients, one of which was the Starfish Program, a palliative care approach to terminally ill patients. I participated in the Care for the Carers seminars that help medical and nonmedical professionals manage personal issues in relation to their work. The seminars were intense and emotionally charged. After some time, I became a volunteer in VCT workshops.
On World AIDS Day in 2009, I participated in a panel discussion at the World Health Organization regional office in Manila on HIV incidence among Filipino MSM where I shared an article I have written in response to a news story on the rising incidence of HIV infection among MSM and the dynamics that contributed to the sudden increase of HIV infections. I recommended the following: •
Aggressive outreach activities such as HIV and STI screenings in bars or clubs frequented by MSM. Internet websites and publications should be utilized to send messages on HIV prevention and treatment. Interventions should be modified if necessary, and program activities must be designed with modern technology such as Internet and text messaging. There is no ‘one size fits all’. Preventive messages should be tailored to appropriate ages within the MSM subgroup.
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A nationwide summit or dialogue with government, NGOs and
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Making a positive change W
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•
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•
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Make HIV testing part of routine health care, the way it’s done with diabetes and hypertension. Pre-test counselling must be client-centered so that the root cause of risks are identified and addressed immediately, such as internalized homophobia, low self esteem and self worth. It will also address issues of stigma and discrimination. Easy access to condoms and literature in bars, clubs, motels, hotels and other venues. Encourage collaboration and dialogue with entertainment establishment owners, local police,
health department and NGOs. Police raids force owners to go underground, which results in difficulties to reach out to high risk MSM. Training should be conducted among volunteers, front line and management staff who provide information to include self care to carers to promote the smooth continuity of services, role clarification, and self awareness.
Bric Bernas is a HIV advocate and volunteer of the AIDS Society of the Philippines.
e r a c , t n e m t a e r T Under the NASPCP supervision, pr of antiretroviral (ARV) drugs starteocurement d in
September 2005 with funding sup port from the Global Fund Round 3 HIV Project. The issuance of Memo randum Circular No. 2006-0026, “Guidelines on Access and Utilizat ion of Anti-Retroviral Drugs Procur ed through the Global Fund to Fight AID S, Tuberculosis and Malaria (GFATM) for HIV/AIDS Patients from the Six Treatment Hubs” on April 24, 2006 provided the initial experie nce. There are now 13 treatment hubs. Prior to this, only the San Laz aro Hospital (SLH) and the Resear ch Institute for Tropical Medicine (RITM ) are capacitated to manage patien ts on ARV treatment. Even PLHIVs from the province needed to go to these hospitals to avail themselve s of treatment. The current provision of ARV trea tment, care and support to PLHIV is guided by the DOH Adm inistrative Order on Guidelines on ARV Therapy for Filipino Adults. Each treatment hub has a HIV AIDS Core Team (HACT), a multidi sciplinary team composed of a physician, nurse, dentist, social wor ker and medical technologist tha t provides a holistic approach to the treatment and care for PLHIV. A treatment hub is trained to provide prevention services such as HIV counseling and testing, prevention of mother to child transmission, clinical management of HIV and AIDS including ARV and treatme nt of opportunistic infections, and car e and support services to PLHIV including networking with suppor t groups and services.
and support
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stakeholders. Caregivers can represent the “closeted or invisible men” to voice out their needs and concerns.
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adherence training for community workers; and a national convention for PLHIV, affected families and significant others.
capital seed money; enrollment of PLHIV in social health insurance; referral to the social hygiene clinic for voluntary counseling and testing (VCT), referral to treatment hubs of newly diagnosed persons and psychosocial support to PLHIV or affected families through home and hospital visits; antiretroviral
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he Positive Action Foundation Philippines Inc. (PAFPI), in collaboration with the Pinoy Plus Association Inc. (PPA) were tasked under the Project to manage treatment, care and support services for PLHIV that include with training and capacity building on establishing cooperative and provision of initial
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PAFPI president Joshua Formentera meeting with fellow PLHIV
An ARV literacy workshop and an Adherence Counseling Training were conducted between September and October 2008. A SelfEmpowerment Workshop was conducted after a series of consultations with the positive community, consultants, facilitators and the
DOH. The activity aimed to help the PLHIV cope with the psycho-emotional effects and reduce anxiety after discovering their HIV status. Results indicated that participants perceived that their willingness and capability to improve the quality of their life significantly were enhanced after the training. Qualitative feedback from the participants indicated the occurrence of positive changes as a result of attending the training. The participants all agreed the was a big help and that they would recommend this to other PLHIV. The positive community recommended the extension of the self-empowerment workshop and to scale up coverage to address the need to mitigate the impact of HIV in the lives of the PLHIV. The HIV-positive community has been instrumental in strengthening the VCT among migrant workers’ diagnostic clinics. Presently, the Bureau of Health facilities and services accreditation has integrated the need to set up VCT structure in the accreditation of migrant workers’ diagnostic clinic. Working effectively with TCS non-government organization and DOH, the team was able to bridge this policy improvement.
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Empowering persons living with HIV
Access to social health insurance as mandated by the Philippine AIDS Law (RA 8504) was devised to alleviate the impact of infection and improving the health-seeking behavior of those directly and indirectly affected. PAFPI enrolled 200 PLHIV for the years 2008 up to 2010 in July 2009. Through a validation study, there were 16 PLHIV, or 8% to 10% who accessed the 10% discount for confinement and other medical procedures such as chemotherapy and surgical operation. Most of the PLHIV expressed appreciation to the aid extended to them by the Philhealth Inc. The sustenance of continuum of care was assured with the enrollment of more PLHIV and to further mitigate its impact to the quality of lives of those infected and affected. There is a need, however, to strategically place the sustainability of their enrollment.
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Positive feelings
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my, a PLHIV, used to feel that she was confined in a box. “I couldn’t cope with fear of being discriminated upon because of my condition”, she said. Amy’s co-worker, Romy, has his own take on himself. “I felt that I was not normal and I was different because I have HIV.” Amy and Romy are employed by the PAFPI., an organization providing care and support to PLHIV. In April 2009, they attended a self-empowerment training (SET) as part of the process of their continuing education about living with the virus for more than nine years.
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The two PLHIV could only look back now at those days when they were newly diagnosed as HIV positive. Without the help of the NGOs that have been fighting for their welfare for more than 20 years, and their various interventions such as VCT, peer education, care and support to PLHIV, IEC development, and life-skills workshops, they would still remain in fear and shame. The NGOs and their efforts played a big role in their recovery and healing. Amy and Romy’s continuous
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advocacy on HIV and AIDS prevention and their being former overseas Filipino workers paid off, as they were given important roles in the Project with the implementation of Prevention and Mother to Child Transmission (PMCT) program. Amy now feels confident to face people because of the training on self empowerment. “I wouldn’t be able to face my peers had I not participated in the training”, she said. She hopes that she has made a difference to her peers, especially the new ones. “I’m craving for more self learning activities like the SET because it is my venue to explore myself more.” As for Romy, he feels happy that he has a supportive family. “My wife and children were part of my journey during my gloomy years”, he said. “It was a love and hate relationship for me and my wife for a while, yet, she remained a loving wife and a mother to my children because she decided to join my journey in understanding my condition.” His wife was the one who encouraged him to join the workshops by PAFPI where Romy works as a messenger. She also became a constant participant of the organization’s initiatives.
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r. Rita Bantigue, a psychologist and a trainer in the Self Empowerment Training (SET) workshop in 2009, shared her qualitative feedbacks from PLHIV. The activity unfolded thoughts and feelings from PLHIV, which helped them understand the importance of coming up with action plans to develop a positive self-image, to learn knowledge and skills on how to cope with depression, anxiety, anger, guilt and feelings of helplessness, to learn problem-solving and decision-making skills, to develop career plans and develop action plans on how to enhance relationships with significant people in their life and improve their physical, mental, spiritual and emotional well being. The PLHIV were guided by questions as part of their self assessment. Their messages were heard and written and their future steps determined their hopes to improve the quality of their life. Focus, time management, self acceptance, good direction, strong, moving on, recovery, inspiration, sharing, challenge, and solution were the words that described their experience after the workshop, realizations that motivate them to face the world with positive outlook in life.
One HIV-positive person said, “There is indeed sunshine after the storm”, enveloping PLHIV’s feelings and thoughts to keep on looking on the brighter side of life in spite of the difficult situations they face due because of stigma and discrimination. “Life is a drama, its story changes as we go through each chapter” according to another. This drama contains different phases of life. The PLHIV looks at this phase as a challenge in choosing what is right and wrong, about self control and love. Yet, there is always a room for improvement that will teach one to face life with humility. For another PLHIV, one phase tells about adherence to ARV drugs. The process of understanding the importance of medication in their life was clearly defined in training. Those who are just starting to get in to the process of taking ARV were enlightened and began to appreciate their life. They all recognized that continuous efforts are being done by many, most especially medical practitioners, to help PLHIV prolong their life and eradicate stigma and discrimination. The SET is one of the many examples of effective intervention being done even in the past which made a great impact to PLHIV in different backgrounds.
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Living with the virus
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An awakening
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aniel Garcia was 22 years old when he began his volunteer work for an NGO in 1997. His active involvement in social development activities opened his eyes to harsh realities, especially in Angeles City. But among many societal problems that he has come to grips with, Dan is most affected by stigma and discrimination against PLHIV. As a barangay official in 2007, he witnessed how people in a neighborhood harassed an HIV-infected couple and their two children because of their disdain for the couple’s HIV infection. His voice still trembled when he recalled the incident. “I’m emotional because I saw what happened. The people planned to burn them”, he said. ”It was painful. I knew that they should not be treated that way”, he added. He was well aware that there is a law that protects PLHIV from any form of discrimination. He was relieved when the City Health Office came to rescue the family. The CHO officials were also able to pacify the people by educating them about HIV and AIDS. It was a rapid response, and Dan was very impressed at how the CHO took actions. But he said the process was not that easy. He recalled that the couple struggled because their children had to be temporarily taken away from them to protect them from the irate mob. Since then, Dan’s passion to help people intensified. He allotted time for training on health issues especially HIV and AIDS to better protect himself and gain knowledge to share to his co-workers, family and friends. February 2009 was one of the most exciting months for Dan. He became a peer educator of the CHO. His knowledge on HIV and AIDS were refreshed and updated through the series of trainings, his communication skills enriched and his attitude towards life was enhanced. “I have a clearer direction now on how I would utilize my capacities as a public servant and at the same time advocate for HIV prevention and other health–related issues,” he said.”I also dream of having my own information center on STI, HIV and AIDS where there is an active participation of the community in promoting a healthy environment.”
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n the 1990s, HV-infected individuals usually succumb to opportunistic infections and die without receiving any treatment. Only those with relatives or friends abroad who can send ARV drugs to the Philippines can avail themselves of treatment. At that time, importation of ARV drugs was not allowed in the country. A French NGO provided the drugs free, through importation, to a Philippine NGO that paid the taxes. Today, they are available and free to PLHIV because of the efforts of Global Fund projects, other donor agencies, NGOs and the DOH. The issuance of DOH Administrative Order No. 2005-0007 on March 31, 2005 exempting the requirement of the Certificate of Product Registration to all goods procured through UNICEF, WHO, UNDP and Global Fund provided better access to ARVs. Locally manufactured or imported pharmaceutical products needed to acquire Food and Drug Authority certificates.This exemption facilitated and legalized the entry of these drugs to the country. ARVs can only be accessed through these treatment hubs, which also receive drugs for prophylaxis and treatment of opportunistic infections from Global Fund and NASPCP. Under GFR3, there were only six treatment hubs -SLH, RITM, Philippine General Hospital, Ilocos Training and Regional Medical Center, Vicente Sotto Memorial Medical Center and Davao
Medical Center. Five more were added during the GF Round 5 project with the inclusion of Baguio General Hospital and Medical Center, Zamboanga City Medical Center, Western Visayas Medical Center, Corazon Locsin Montelibano Memorial Regional Hospital and Bicol Regional Training and Teaching Hospital. Two more were added under GFR6 - Cagayan Valley Medical Center and Jose B. Lingad Memorial Medical Center. The NASPCP envisioned that there should be at least one treatment hub per region. Although their main role is to clinically manage the PLHIV, the HACT of these hospitals provide psychosocial support. Since the team members are not usually trained on this aspect, they usually coordinate with the treatment, care and support NGOs and other support groups. The two treatment hubs with the largest number
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Proud to advocate for HIV prevention
The heart of treatment, care and support for people living with HIV
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Desensitization activity
of patients on ARV, SLH and RITM, coordinate closely with these NGOs such as PAFPI and Pinoy Plus. Treatment hubs outside of Metro Manila are supported by NGOs in the provinces such as Empowered of Western Visayas, Inc. in Iloilo, Cebu Plus and Alliance against AIDS in Mindanao, Inc. in Davao. Psychosocial
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employees also need training on self care that teaches them to care for personal needs including emotional and spiritual. There is also a home based care training carers PLHIVs that is provided by the hospital. It teaches them how to take care of the PLHIV once they are already discharged from the hospital. Treatment hubs provide holistic approach in managing PLHIV. Aside from providing treatment and psychosocial support, SLH is also able to look after the spiritual welfare of their patients through the help of religious and lay organizations such as the Order of Malta and Daughters of Charity. The priest assigned at the hospital’s chapel is also available to give the sacrament of anointing of the sick. H4 ward doctors do not only provide treatment to their living patients but go out of their way to raise funds to provide a decent burial to their dead patients.
Counseling workshop
tigma and discrimination are the two factors that obliterate ventures towards care, treatment, and support to PLHIV. They prevent PLHIV’s access to needed services and may expose their HIV status to their families, workplace, and community. Worries about family denunciation, denial in employment and public rejection hinder the effectiveness of HIV and AIDS prevention and care efforts. Impressions about the lifestyles of PLHIV contribute to the notion that HIV and AIDS are problems that affect “others,” and which may demoralize individuals’ estimation of their own risks and reduce their motivation to take preventive measures. One of the critical factors for the country’s response to HIV prevention is the reduction of stigma and discrimination. Stigma negates any increased efforts to put all PLHIV in the health care setting especially with the DOH and Global Fund partnership to provide universal access to antiretroviral drugs. The Project is taking stigma reduction as a strategy in the context of a supportive environment. The project has already trained 1, 543 community members and 1,394 healthcare workers from different targeted sites. A major output was the allocation of a local budget for the LGUs on the continuous advocacy for high school and college students and to youth at risk. A school-to-school program on awareness, updating of information on the local STI and HIV data, and ensuring available services are provided through their SHCs. Healthcare workers participated in orientations on STI and HIV basic information that will be included in their pre-employment orientation and the proper treatment, care and support given to the PLHIV and their affected families.
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Dr. Jeniffer Feliciano and Dr. Rosanna Ditangco distribute certificates
support includes counseling, facilitation of disclosure of the patient’s HIV status to the family and assistance in seeking financial support for indigent PLHIV, especially hospitalized patients. RITM and SLH initiated trainings to improve the quality of life of their patients. RITM, in partnership with PAFPI, provides empowerment trainings to PLHIV. San Lazaro conducts palliative care training to new nurses and nursing assistants of the hospital’s H4 Ward. Palliative care entails providing care and comfort to dying patients. Another unique training by SLH through the Starfish Foundation is the training on self-care for hospital employees assigned to the H4 Ward. San Lazaro’s HACT recognizes the emotionally taxing work of caring for PLHIV that hospital
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PLHIV in the country, having been diagnosed in August 1993 when ARVs
were not yet available in the Philippines. Bobby witnessed the evolution of ARV treatment from the days when the drugs were literally smuggled into the country up
Free ARVs
T
to today when they are provided free. To date, more that 800 people are on ARV therapy in specially trained treatment hubs across the country. Stigma and discrimination also limit the access of MARPs in the social hygiene clinics and VCT centers, considering that the Project will capacitate 16 SHC and 12 hospital based VCT centers in its project sites. There is also the HIV and AIDS Orientation Seminar for Stigma Reduction in Hospital Setting that aims to reduce stigma among
and
discrimination
PLHIV
and
the
most at risk populations by increasing awareness among health
care
workers
and
making available HIV related services. Six hospitals and 381 hospital staff have been
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given orientations.
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Out & about
his is probably one of the fastest – or dizzying – periods of my life. I’m almost 37. I worked as the Project focal person for Puerto Princesa on a voluntary basis since I have a regular job as a science teacher at a private school. I had my university training in the natural sciences and creative writing. To start with, I am an MSM. That’s how I got “entangled” with the program. I’ve been living selectively out and partly undisclosed to my family. Prior to my teaching post, I was an editor of a local newspaper, working my way up from being a field writer rummaging through the streets or slums for angles on everyday issues. During free time, I was often involved as a technical staff for activities related to the gay community in Palawan. I did audio-visual work for pageants and local shows in the city. But I was never involved in frontline activities for these shows. In 2007, I was approached by the doctor of the social hygiene to think of something that will inform people about STI. I did not know how to do it. I could not begin writing about diseases that involved issues considered déclassé in social circles, although the news organization I was working with has a reputation for being at the forefront of developmental issue reporting in this corner of the country. In 2008, with the STI program
of the clinic conducting initial approaches to the most at risk sectors, I was able to attend an awareness seminar conducted by Tino Ramirez of PAFPI. I brought along an MSM acquaintance to attend the seminar. The hall was full of teenage cross-dressing MSM. I felt like an island in a sea of beautiful queens, worrying about the whereabouts of guys like me who should be attending an awareness activity. From a hindsight now, my earlier involvement (be it on a technical capacity) with entertainment-related activities probably desensitized me about traditional gay behavior and had created an opening to the network of overtly out MSM. On the other hand, this has also worked to a disadvantage in some situations when some MSM do not want to be seen hanging out with a person who has been “among gays” (as one of the covert MSMs in the city said). But this is also part of my personal goals, to serve as a positive model to the MSM and society as a whole, that MSMs are everywhere and do varied jobs, to lessen the stigma and focus on the risk behavior model of prevention instead.
Serge A. Pontillas, a teacher, is the focal person of the Project site in Puerto Princesa City.
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B
obby is one of the longest living
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Treatment Hubs
Local Government Units City Health Offices Social Hygiene Clinics
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Ilocos Training and Regional Medical Center (ITRMC) San Fernando, La Union Dr. Jeisela B. Gaerlan Medical Specialist II / HACT Leader Clinic: (072) 700-3808
Philippine General Hospital (PGH) Taft Avenue, Ermita, Manila Dr. Jodor Lim / Ms. Dominga C. Gomez HACT, SAGIP / PGH Telefax: 526-1705
Baguio General Hospital and Medical Center (BGHMC) Baguio City Dr. Maria Lorena L. Santos HACT Leader / Medical Officer II
Bicol Regional Training & Teaching Hospital Legaspi City, Albay Dr. Rogelio G. Rivera Chief of Hospital III Tel: (052) 483-0016 / 483-0086 / 483-0017
San Lazaro Hospital (SLH) Quiricada St., Sta. Cruz, Manila Dr. Rosario Jessica Tactacan-Abrenica Medical Specialist II / HACT Leader Head, HIV/AIDS Pavilion Tel: 309-9529/28; 740-8301 local 6000 Research Institute of Tropical Medicine (RITM) Filinvest Corporate City, Alabang, Muntinlupa City Dr. Rossana A. Ditangco, Head, HIV Research Unit Tel: 526-1705; 807-2628/38 local 801/208
Western Visayas Medical Center (WVMC) Q. Abeto St., Mandurriao, 5000 Iloilo City Dr. Ray Celis HACT Leader/Medical Specialist III Tel: (033) 321-2841 to 50 Corazon Locsin Montelibano Memorial Regional Hospital Lacson St., Bacolod City, Negros Occidental Dr. Candido Alam HACT Leader / Medical Specialist Tel: (034) 435-1591; (034) 433-2697
Vicente Sotto, Sr. Memorial Medical Center (VSSMC) B. Rodriguez St., Cebu City 6000 Dr. Maria Consuelo B. Malaga, HACT Leader Tel: (032) 253-7564; (032) 253-7564 / 9882 Zamboanga City Medical Center (ZCMC) Evangelista St., 7000 Zamboanga City Dr. Jejunee Rivera HACT Leader / Medical Officer III Tel: (062) 991-0573 Davao Medical Center (DMC) J.P. Laurel St., Bajada, 8000 Davao City Dr. Alica Layug, HACT Leader Tel: (081) 227-2731 Cagayan Valley Medical Center Tuguegarao City, Cagayan Valley Jose B. Lingad Memorial Medical Center San Fernando, Pampanga Or visit / inquire at: Nearest Social Hygiene Clinics (Special STI Clinics); City/Municipal Health Offices NGO Partners at the local level
Generating support The GFR6 supports national and local level program development
initiatives including setting up of Local AIDS Councils, local ordinances, linkages to other sectors’ programs such as those of OWWA and POEA and referral systems for PLHIV from LGU to treatment hubs to care and support NGOs. The project also funds big advocacy events such as World AIDS Day, AIDS Candlelight Memorial and other locally initiated advocacy events. Support to capacity building for the NASPCP and program partners are also covered under the Project.
for greater e s n o p s re
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General Santos Puerto Galera, Oriental Mindoro CHO: Dr. Josefina Chua Mayor Pedro Acharon Jr. Mayor Hubbert Christopher Dolor, MD SHC: Dr. Jesus Chin Chui TF: 083-554-4212 TF: 043-442-0182 CHO: Dr. Jacinto Makilang Municipal Health Officer: Puerto Princesa Palawan SHC: Dr. Mely Lastimoso Dr. Ginalyn Caguete Mayor Eduard Hagedorn TF: Davao City Pasay City CHO: Dr. Juancho Monserate Mayor Rodrigo Duterte Mayor Wenceslao Trinidad SHC: Eunice Herrera TF: 082-224-2028 TF: 02-831-5222 082-224-5878 CHO: Dr. Cesar Encinares Caloocan City CHO: Dr. Josephine Villafuerte SHC: Dr. Eduardo Cabildo Mayor Enrico Echiverri SHC: Dr. Jordana Ramitterre TF: Quezon City CHO: Dr. Raquel So-Sayo Manila Mayor Feliciano Belmonte Jr. SHC: Dr. Zenaida Calupas Mayor Alfredo Lim TF: 02-921-6750 TF: CHO: Dr. Antonietta Iñumerable Laoag CHO: Dr. Marie Lorraine Sanchez SHC: Dr. Yolanda Condenuevo Mayor Michael Fariñas SHC: Dr. Dianna Mendoza CHO: Dr. Renato Mateo Angeles City Pampanga SHC: Dr. Imelda Tamayo Santiago City Mayor Francis Nepomuceno Mayor Amelita Navarro TF: 045-323-4105 Cebu TF: 078-682-8110 CHO: Dr. Cherryll Tuazon Mayor: Tomas R. Osmeña CHO: Dr. Genaro Manalo SHC: Dr. Lucille Ayuyao CHO: Dr. Fe Cabugao SHC: Dr. Robelyn DeVera Go SHC: Dr. Ilya Tac-an Iloilo City Tuguegarao Mayor Jerry Treñas Mayor Delfin Ting TF: 033-335-0689 TF: 078-844-1449 CHO: Dr. Urminico Baronda 078-844-2894 SHC: Dr. Odette Villaruel CHO: Dr. Josefina Chua SHC: Zamboanga Mayor Celso Lobregat Butuan City TF: 062-991-6782 Mayor Democrito Plaza CHO: Dr. Rodelin Agbulos TF: 085-342-5208 SHC:Dr Kibtiya Uddin
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Accep ting
Michael was 18 when he started engaging in sex with multiple partners. “I wanted to have sex every time. That was the only way that I thought will make me feel good about myself”. He perceives that his sexual orientation makes him less important. “In spite of what I have achieved, my parents think I have no direction simply because I’m gay,” he lamented. Out of curiosity one day, he joined a HIV peer education training of the Quezon City Social Hygiene Clinic. “It changed my misconceptions about sex”, he stressed. “I thought I’m safe for as long as I take care of my hygiene. I realized that I’m accountable if I get infected,” he said. “Now, I’m more careful. I limit my sexual activities and consistently use condoms. If I don’t do this, there is no one to blame but me”. After the training, he got involved in condom distribution, intervention for migrant workers, and STI seminars. One of his achievements as a peer educator was being a judge to the Mr. Gay contest in one of the bars in Cubao where he also distributed HIV information. “It feels good to do good things to others especially when they appreciate my contribution”, he said.
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Teaching HIV and AIDS with her peers in Novaliches, Quezon City is one thing that Kaye is really proud of. She feels like a teacher whenever she shares information on HIV and AIDS. The peer education training helped
her put limits on her sexual engagement with customers. Using a condom is her one protection from infections. “I realized that a casual conversation with my peers on what is HIV and AIDS and the disease’s implications in our work could create an impact on our sexual behavior”. Like Kaye, her peers are starting to practice safer sex. She feels her worth every time she affects change to someone who needs help. Her efforts paid off because Kaye is now a barangay health worker.
The reminder Like other gays, Donna could not resist sex to satisfy his urges despite its risks. Peer pressure led him to try paid sex. He was negotiating with customers one night in Quezon City when policemen caught him and his colleagues violating the city’s curfew hours. He was detained for three months. This taught him serious lessons, until he was invited to the peer educators training of the Quezon City Health Office. The training changed his sexual behavior. He started using condoms in every sexual contact. Information about the risks of having HIV became his primary reminder of the dangers of engaging in irresponsible sexual acts. His skills in teaching STI, HIV and AIDS information were developed. He now helps
PE coordinator John Jardenil
in the Quezon City STI, HIV and AIDS project by disseminating information. To top it all, Donna is now one of the city’s barangay health workers with regular stipend. “I came to realize that I should value my body and become a responsible gay partner”, he said, adding that “I hope my experience will help other gays become responsible by always remembering the reminder, “Ingat Lagi”, the GFR6 project’s information dissemination slogan.
Moving forward My work as an active peer ed of the Manila Social Hygiene Clinic started when I joined a peer education training. I familiarized myself with information about STI and HIV, and because I believed in being a role model who must exemplify the behavior that I sought to promote, I voluntarily submitted myself to blood tests to ensure that I am free of infections. I found the training not only enriching. The staff of the Manila SHC and its partner NGOs was technically competent, motivational and supportive. It was required that at the end of every training, peer eds must be sufficiently knowledgeable about the goals, contents and methods of teaching our peers. As we went through field demonstrations in the community, we became competent enough to practice what we’ve learned. Fortunately, we had a lot of experiences that after some time, we gained good feedback from the clients during the activities such as condom distribution, information dissemination about STI and HIV testing and support services, and education and communication campaign materials mostly for people who are vulnerable to infection. Involving myself in this program
helped me gain information about STIs and HIV. Responding to the inevitably growing number of people who are vulnerable to STIs and HIV is one of the greatest challenges faced by the peer education program today. At some point, I found this experience overwhelming, because I volunteered and did my very best to work and cooperate with my colleagues without expecting any personal gain or recognition. While working with the clinic, I got a job as an administrative aide at the office of the Philippine National AIDS Council (PNAC). However, I continue to dedicate myself to being a peer ed because my responsibilities at PNAC are related to peer education, such as assisting clients who want to be tested and referred to the social hygiene clinic for easy access to services. I also attend monthly meetings to be updated on programs. I attend PNAC workshops and work as facilitator in STI and HIV prevention and care programs in places in and outside Metro Manila. Because of the wonderful and inspiring experiences, I hope peer education as a vital factor in STI and HIV prevention will continue to be supported by stakeholders to continuously increase the peer educators’ knowledge and skills.
Ronnie Valino is an administrative aide of the Philippine National AIDS Council. He continues to work as peer educator of the Manila Social Hygiene Clinic.
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Teaching responsible sexual behavior
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something to say to each of the groups and issues targeted under the DOH-GFR6 HIV Project. But first, how did it come about? Like any other slogan, Ingat Lagi underwent a birthing process.The first considerations involved the general public and the propriety of the message, with more reflections given to young people in thinking about a more universal message that can do away with graphic illustrations of condoms and sex, which the Catholic Church opposes.
Students and young people in their 20s and 30s and other vulnerable populations are being infected mainly through sexual transmission, and are also targets of the slogan through messages urging them to delay sexual activity and to increase their knowledge to equip them with life skills. Stop HIV. Peer educators should be armed with this message always. The crucial message is for increasing the awareness among the MARPs and other vulnerable populations.
Ingat Lagi: The medium
Aiming at the general public is urgent because it is becoming more vulnerable, as existing materials are already targeting the MARPs. The process also took pains in referring to “Ingat lagi” or “Take care” that should not be misinterpreted as “Lagot ka” or “Beware.”
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For health care workers, the message aims to increase awareness on HIV and other blood borne infections, occupational exposure, safe injections, and eliminate discrimination. For PLHIV, the message seeks awareness on their protection from infectious agents and prevention. For blood safety personnel and donors, the message is conveyed to paid blood donations and commercial blood banks that may cause the increasing number of cases reported from the blood program. It reiterates the importance of voluntary blood donation and safe testing of blood and blood products.
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Migrant workers, who now number eight million, are also equally becoming more vulnerable, so they are prospective targets of the message. Three out of 10 reported HIV cases are overseas Filipino workers. The send off message could be: Please be careful always! A take home message: Know the risk of HIV. Have yourself tested. The slogan can be posted or distributed in international airports and other ports as a send off embarkation and take home message. In the international airports, the slogan can be inserted in the promotional cards for phone companies Smart and Globe.
Stop AIDS. To pursue the full package of treatment and care interventions against HIV transmission
and programs to reduce death from AIDS, stopping HIV also means stopping AIDS.
New cases, new hopes Puerto Princesa has two newly diagnosed
HIV cases in January 2010. Dr. Eunice Herrera, head of the city’s social hygiene clinic, credited this to the rigorous media campaign of the DOH whose impact to the society may have encouraged these persons to seek her help in counseling and testing. “This is not the first time that we diagnosed a person with HIV. We already had one case last year”, she said.
cesa City. Dr. Eunice Herrera of Puerto Prin
Herrera is hoping for more caring individuals to help stop the growing HIV infection in their city. She is thankful that the two new persons with HIV sought her. They now help in mapping the areas vulnerable to infections. “We plan to double our efforts on HIV and AIDS education campaign by exploring, strengthening and expanding more support systems where the best interest of the people will be protected”, she said.
Multisectoral involvement beyond health Santiago City’s AIDS Candlelight Memorial in May 2009 paved the beginning of the STI Mobile Booth that was part of the memorial program wherein children, in and out of school youth and adults played a significant role in the HIV and AIDS awareness pledge. With the huge participation of young people, the
The partnership continued during the Word AIDS Day celebration. The schools explored their creativity in presentations by preparing chants and dances on HIV prevention and produced tarpaulins and information materials to express their commitment. Dr. Alex Armedilla, mentor of peer educators, said the event had 768 participants, way beyond the expected 400. Medical technologist Maricel Zapanta, a trained peer educator, said “the Project has opened a venue for students to be involved in social concerns. This was helpful because there was no HIV prevention program that would interest young people prior to these
and the message
program’s success enthused Dr. Genaro Manalo, city health officer, and the City Health Office staff to devote time to the welfare of the young who are vulnerable because of their growth phase that may compromise changes in their behavior.
In partnership with peer educators, the CHO and SHC took turns in meeting with schools in the city to promote their booth. Three colleges that initially responded to the call were the North Eastern College, Patria Sable Corpuz College and Santiago City College of Arts and Trades. They took turns in setting up the booth in their schools in separate dates from September to December 2009. Perla Bautista, STI/HIV coordinator, said the students’ reactions to the posters and pictures ranged from excitement to fear. “Oh my God,” “Is that how it looks like?” and “Ayokong magkaganito (I don’t want this to happen to me”), were some of the retorts. “They were very interested to know the symptoms of STIs”, said Bautista. “The schools opened their doors to the initiative and they looked forward for more activities responsive to HIV prevention in partnership with the CHO,” she added.
activities”. Peer education efforts also helped in reaching out to at risk groups, especially in and out of school youth. The CHO and SHC met their target populations. Zapanta said, “I met about 200 MSM in our outreach program. Most of them have undergone voluntary counseling and testing,” she said. “There were about 20 FSWs that I met, and they were also very cooperative.” Dr. Manalo said stigma and discrimination still persists, yet the Project had a unique way in introducing the issue to young people through peer education. He said there are people who are not receptive, some are open-minded about it and others are simply not ready. Optimism through constant intervention is a way to encourage people to empathize with HIV issues. He said reaching FSWs was not easy since they are more mobile than the MSM, yet working with the establishments was a big help in gathering the mobile FSWs. Dr. Manalo said the promotion of STI and HIV awareness in the booth and peer education with high school students was a milestone in providing protection to community people against STI, HIV and AIDS.
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“Ingat Lagi: Stop HIV. Stop AIDS” has
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artnerships do not only foster friendships; they also contribute to better work efficiency. This is the case of the Manila Social Hygiene Clinic that works with peer educators and NGO partners in providing services for STI and HIV awareness and prevention. Under the Project and with the AIDS Society of the Philippines, the Manila SHC involves the Remedios AIDS Foundation, Positive Action Foundation Philippines, Inc. and Pinoy Plus Association in providing services in its HIV prevention activities. STI coordinator Malou Tan said the partnership is an effective strategy to reach and sustain communications
resilient”, she said. “For recovery and healing, we also refer HIV-positive clients to support groups”.
with the MARPs and in referring individuals in need of specific services. “We get in touch with an NGO to refer an HIV-infected patient who wants to talk to another HIV-positive person, hoping that it will lessen their burden and to let them know that there are existing care and support groups that could help them become
The SHC and NGOs have a give-and-take relationship that involves linking and their partnership improves the quality of their work. The partnership enables clients to avail themselves of different services. “We complement each other”, said Tan. The clinic provides the VCT and some NGOs provide access to treatment, care and support activities. She said the involvement of young people in the STI and HIV and AIDS prevention is one way of exercising their right to participate on matters affecting their lives. Continuous provision of appropriate skills and training and including them in important advocacy events and activities of the local governments help shape their response to HIV pandemic.
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n Puerto Princesa, basic peer education for MSMs is carried out by the GFR6 volunteers who fan out in their respective communities and favorite places for entertainment or “gimik”. The volunteers are MSM in their late teens or early 20s, so this makes interaction with other MSM a non-awkward proposition. These volunteers carry out the education, prophylactic-distribution tasks, and occasional referrals for HIV antibody testing or STI care and prevention services of the clinic. The city started utilizing the power of the internet in reaching out to MSM, who are not “out” (“bisexuals” or masculine gays), non-gender identified (NGI) (“trippers”), or not working in the industries traditionally associated with MSM are reached through the help of the internet. The Puerto Princesa Social Hygiene Clinic has no official website, but the MSM utilize the international MSM social networking sites in interacting with users on a case-to-case basis. There is a substantial enrollment of MSM from Puerto Princesa in the following social networking sites: Guys4Men. com (now planetromeo.com) and Manjam.com.
The most recent batch of PLHIV who were tested in the area was a result of peer networking with users of the MSM social networking sites. This was followed up with face-to-face meetings. Although the latest PLHIV were not communicating directly with the volunteer prior to testing, the peer-educated internet user served as the bridge in informing his friends about the free, confidential and reliable HIV antibody testing in the site clinic. The internet provides a reliable jump-off point from which face-toface outreach can develop. Initiating the basic peer-to-peer social “handshake” in the internet normally follows the same social protocol used for meeting peers in non-internet-assisted situations. User volume and website activity also serve as two of the monitoring frames from which we can view the dynamics of local MSM and interaction between local and itinerant MSM who are ordinarily a part of the burgeoning tourism industry in Palawan.
Networking In 2009, two GFR6 volunteers were invited into the project through the social networking sites. The accounts used to monitor these sites contain simple prevention messages; basic information on the current HIV epidemic in the Philippines; the existence of a peer education volunteer program in Puerto Princesa and the availability of confidential free HIV testing and counseling. The recruitment for the two volunteers via internet falls under the category of passive recruitment since the two volunteers were the ones who sent messages inquiring about how they can become volunteers.
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Working with NGOs P
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he PLHIV are getting more organized and committed to their cause. The Project supported the conduct of the third National Consensus and Consultative Meeting that gathered PLHIV on December 14, 2009. Through this gathering, the community created the National Association of Filipinos Living with HIV and AIDS (NAFWA), which joins the growing number of HIV support groups in the Philippines in the wake of increasing HIV cases and continuing interventions in treatment, care and support. NAFWA is envisioned to further unify the voice of PLHIV and to ensure their meaningful involvement in the national response and program for treatment, care and support for infected persons and their affected families. NAFWA was created through the efforts led by the PAFPI with the support of existing support groups such as Babae Plus, Pinoy Plus Association, Empowered of Iloilo, Crossbreeds of Bacolod, Cebu Plus and the Mindanao Advocates. The organizations joined forces to draft a national working plan and form different committees. Joshua Formentera, president and chief executive officer of PAFPI, said the new group aims to strengthen a strong network of PLHIV in the Philippines. “Individual and organizational commitments, sharing of information, experiences and lessons will help push for positive reforms for a national response,” he said. He said the engagement of PLHIV is more urgent now because of increasing cases and the need to scale up effective and responsive national AIDS responses with the greater involvement of PLHIV.
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Children and women were also given importance. The organization drafted viable action plans that could further their cause such as research on gender-based violence on positive women, implementation of child protection policy and the passage of the reproductive health bill. Lorna Garcia, President of Babae Plus, stressed that “affected family members are highly encouraged to join the discussion on men’s health and reproductive health issues. She also stated the need to create a database on children affected and infected with HIV.
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HIV & faith:
Sexuality is God’s gift to human beings “So God created human beings, making them to be like Himself. He created them male and female, blessed them….” (Genesis 1: 27).
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n the story of Creation, God created human beings with innate rights in order to live a responsible life as stewards of God’s creation when He entrusted the whole world to them. A concrete manifestation of God’s giving importance to life is that He ensured that before creating human beings, He provided all that is needed in order to live a blessed and bountiful life. The story also emphasized God’s blessing of creating them male and female. This would also explain to us that even from the very beginning, God created and entrusted to human beings their sexuality as a gift. The Church as an advocate of human rights must stand firm in the midst of the prevailing disrespect for life, in the continuing abuse and misuse of God’s gift. Christian morality teaches us the purpose of sex when God created it. Sex is sacred. AIDS, as we all know, is only one of the diseases transmitted through immoral sexual intercourse. Surveys tell us that not only the morality of Filipinos is degrading fast if we look at the age of those who are engaged in sexual intercourse. In addition, same sex intercourse is also rampant. Sex has become a commodity. Sexual intercourse outside marriage has
become a trend. It became an object that lost its value and purpose. It is no longer a blessing that came from God that would manifest His favor upon a person. Having said this, AIDS threatens our existence as humans created in the image and likeness of God. I was given the chance to participate in the celebration of the AIDS Candlelight Memorial in memory of the men, women and children who died of AIDS, and it was an opportunity for me to evangelize and remind the purpose of our existence; to go back to the basics and bring back the dignity of human beings; to remind God’s purpose for us, and to become instruments of life, a life that is fully lived without fear of diseases. Let us not forget that the greatest gift of God is life. As Jesus said, “I have come in order that you might have life – life in its fullness.” (John 10:10) The Lord is commanding us to protect life. We are called by God to give light to all who are living in darkness, to give life to the dying, to become human rights protectors and advocates. So keep your candles burning.
Fr. Joshua Cuartero is a priest of the Iglesia Filipina Independiente in one of the project sites.
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PLHIV as partners T
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Events
including setting up of Local AIDS Councils, local ordinances, linkages to other sectors’ programs such as those of OWWA and POEA and referral systems for PLHIV from LGU to treatment hubs to care and support NGOs. The project also funds big advocacy events such as World AIDS Day, AIDS Candlelight Memorial and other locally initiated advocacy events. Support to capacity building for the NASPCP and program partners are also covered under the Project.
Lighting candles for AIDS advocacy
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The GFR6 supports national and local level program development initiatives
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Emong Feria GorioHuaningIsangJolinaKikoMaringLando Quedan Rami TinoUrdujaVintaWilmaYolanda Zoraida AgatonBasyang CaloyDomeng Este Bong Diane Marries Boying Ramil Poty Jennifer AuringBisingCrising Dan Henry Inday Juan Katring LuisNenengOmpongPaeng Queenie Reing Senia Usman Venus WaldoYayangZenyFeriaGorioHuaningIsangJolinaKikoMarin Quedan Ramil Santi Tino Urduja VintaWilmaYolandaZoraidaAgaton CaloyDomeng EsterFloritaHenryIndayJuanKatring Luis Neneng Omp Queenie Reing Seniang Tomas Usman VenusWaldoYayang Zeny Nena Gaby Paul MalouBong Diane Marries Boying Ramil Poty Jennifer Auri Crising Dante Emong Feria GorioHuaningIsangJolinaKikoMaringLand Ramil Santi Tino Urduja Vinta Wilma Yolanda ZoraidaAgaton CaloyDomeng EsterFloritaHenry Inday Juan Katring Luis Neneng Ompon QueenieReingSeniangTomasUsmanVenusWaldoYayang Zeny Feria Gorio Huan Jolina Kiko MaringLandoQuedanRamilSantiTinoUrdujaVintaWilma Yoland Agaton Basyang CaloyDomeng Ester Florita Henry Inday JuanKatring Lui OmpongPaeng QueenieReingSeniangTomasUsmanVenusWaldoYayang Zeny N DuringGirlie the AIDS Candlelight basic information on STIs,Jun HIV Amy Tris Paul Malou Honest Rita Mely Tony Mina Sammy Thercy Memorial in Santiago City, the AIDS. STI coordinator Bong Diane Marries Boying Ramil and Poty Jennifer AuringBisingCrisin CHO gathered 10,000 signatures Perlita Bautista said this Emong Feria GorioHuaningIsangJolinaKikoMaringLando Quedan Rami advocating for HIV prevention. implied that people welcomed TinoUrdujaVintaWilmaYolanda Zoraida AgatonBasyang CaloyDomeng Este The event involved 37 barangays, the advocacy. “The candlelight Henry Inday Juan Katring LuisNenengOmpongPaeng Queenie Reing Senia people’s memorial was very touching. Usman school Venusorganizations, WaldoYayangZenyFeriaGorioHuaningIsangJolinaKikoMarin NGOs, and public I felt the sympathy of people Quedan organizations, Ramil Santi Tino Urduja VintaWilmaYolandaZoraidaAgaton and private hospitals. The to PLHIVs present in the Neneng Omp CaloyDomeng EsterFloritaHenryIndayJuanKatring Luis were provided with ceremony”, she said. Queeniesignatories Reing Seniang Tomas Usman VenusWaldoYayang Zeny Nena Gaby Paul MalouBong Diane Marries Boying Ramil Poty Jennifer Auri Crising Dante Emong Feria GorioHuaningIsangJolinaKikoMaringLand Ramil Santi Tino Urduja Vinta Wilma Yolanda ZoraidaAgaton CaloyDomeng EsterFloritaHenry Inday Juan Katring Luis Neneng Ompon QueenieReingSeniangTomasUsmanVenusWaldoYayang Zeny Feria Gorio Huan Jolina Kiko MaringLandoQuedanRamilSantiTinoUrdujaVintaWilma Yoland Agaton Basyang CaloyDomeng Ester Florita Henry Inday JuanKatring Lui OmpongPaeng QueenieReingSeniangTomasUsmanVenusWaldoYayang Zeny N Paul Malou Girlie Honest Rita Mely Tony Mina Sammy Thercy Jun Amy Tris CaloyDomeng EsterFloritaHenryIndayJuanKatring Luis Neneng Omp Queenie Reing Seniang Tomas Usman VenusWaldoYayang Zeny Nena Gaby Paul MalouBong Diane Marries Boying Ramil Poty Jennifer Auri Crising Dante Emong Feria GorioHuaningIsangJolinaKikoMaringLand Ramil Santi Tino Urduja Vinta Wilma Yolanda ZoraidaAgaton 89 CaloyDomeng EsterFloritaHenry Inday Juan Katring Luis Neneng Ompon
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World AIDS Day
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10,000 Signatures
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Annual Partners Meeting
STI Convention
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THE WAY
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W
hile the country is at the forefront in the conduct of a second generation surveillance and has been implementing a passive reporting system of cases, there is a growing clamor for the availability of strategic information in redesigning national policies and developing strategies for better services and effective advocacy materials for key leaders. Local governments should have an understanding of their situation, because only through wellinformed understanding of the population groups, behavior that puts them at greater risk and the potential bridges of epidemic can local prevention efforts really be able to prevent new infections. The main attributes for further development of the response is lodged in the availability of strategic information such as best practice models, operational researches, serological and behavioral surveillance and monitoring of services on HIV related services such as condom distribution, HIV counseling and testing, STI cases and people reached for HIV prevention education.
The DOH-GFR6 HIV Project, through the NEC, has been successful in implementing surveillance with local involvement and in expansion of sites to aid in further developing surveillance infrastructure. Such move is a step in the right direction both for capacity building on how to generate accurate information on the local situation and for the first hand experience tin utilizing such information in program strengthening activities. However, the lack of human resource complement may also cause disruption on the regular service provisions by service providers. Health care workers in social hygiene clinics and volunteer peer educators appreciate the involvement as they can have the technology to fully understand the local situation. The utilization of the information generated should influence the development of advocacy plans, programmatic refocusing, building broader coalitions and partnerships and setting priorities with available resources. Projects can only offer facilities to test innovative strategies that can be replicated on a bigger scale. The mechanism and tools in reporting
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GFR6 Participates in the 9th ICAAP
FORWARD
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Joel Atienza, GFR6 HIV Project technical component manager for HIV
Building and Supporting Effective Mechanism
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Reaching MARPs at Greater Coverage
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While the Project has shown important practices or beneficial experiences that could guide the country’s development of intervention, we sometimes missed on the physical warm bodies that we need to reach for us to be more effective in reversing the epidemic. There are perennial challenges of dealing with hidden populations, running parallel or in conflict with other agencies’ policies and simply neglecting segments of the population because of the bigger issues faced by national and local governments. Our old approaches of reaching conveniently the entertainment establishments had made
LGU Involvement The Philippine National AIDS Council is espousing the development of LACs among LGUs especially those identified as vulnerable. Several good governance best practices had been given emphasis to elucidate the role of a well organized and well-funded LAC that can contribute to the provision of effective HIV prevention activities and increasing coverage. The GFR6 is in full support of locally-led response regardless of the nature of the policy or decision making body the LGU response chooses. Half of the GFR6 project sites, specifically the former ASEP sites Angeles, Quezon City, Pasay, Cebu, Iloilo, Davao, General Santos and Zamboanga, do have existing LACs when the Project started, but the more telling hint for the local programs’ success is lodged on the availability of the well defined programs enacted through a local ordinance. Most of these sites were able to Dr. Gerard Belimac, enact enabling NASPCP ordinances that program manager secure regular budgets for HIV and STI programs. The setting up of LACs in other project sites such as Santiago City
and Manila, the revival of the LAC in Tuguegarao City, Puerto Princesa, Butuan and the continuing process of establishing the LAC in Puerto Galera should not be the end point but the start in enacting a long term sustainable local programs for identified priorities of the LGU. While the country’s epidemic is evolving, there is a concern on how we can further firm up effective structures that will guarantee continuous provision of critical services and information to stakeholders. Local AIDS Councils most of the time provide a better working environment but is not necessarily the only solution to the problem.
Establishing Health Facility Infrastructure for Diagnosis, Treatment and Care HIV counseling and testing is the bridge intervention in the NASPCP’s development of a continuum of care from prevention and treatment, care and support. RA 8504 has a clear policy in HIV counseling and testing, which includes the conduct of pre and post test counseling as well as non-mandatory. The GFR6 as a Project is centered in the development of VCT systems as a health sector response. VCT, however, is seen as the whole gamut of facilitating access to interventions such as HIV prevention information, STI case management, prevention of mother to child transmission of HIV, reproductive health services, ARV treatment, basic care and psychosocial support and referral to other nonmedical services such as livelihood and social protection. The experience of Manila as a full pledged VCT center is phenomenal, having effectively reached very hidden and discrete MSM populations in Metro Manila through peer outreach and referrals. It can be learned that the case of Manila is not comparable to other SHC as it focuses only on STI/HIV
service provision and is not involved in the regulation of entertainment establishments and their workers. The challenge in the low and moderate acceptability of HIV testing is slowly being addressed by increasing the number of trained counselors. There is a need to popularize VCT in a new name or in a different approach to more appealing to intended target populations and not necessarily create a greater demand for services among the low risk general population. ARV Treatment for PLHIV is one of the most important breakthroughs in the Philippines’ response. The support of Global Fund project in starting up the system and the ARV drugs opened up planning and programming to further develop service improvement initiatives by the NASPCP and its partners. In 13 treatment hubs distributed across the archipelago, a little less than 800 are already benefiting from the life-saving medications and more PLHIV have benefitted from psychosocial and basic support to include their significant others. One of the very open success stories is on how the PLHIV were engaged not as beneficiaries but program partners. The experiences of positive community and the speedy propagation of the message of compassion to PLHIV has generated more hope and positive outlook for some of the people who were provided with ARV regimen, or underwent self empowerment training or even just an enrolment and access to benefits of the social health insurance system. Meaningful involvement should continue to be the guiding principle in designing the country’s response.
Dr. Ferchito Avelino, head of the PNAC Secretariat
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HIV related services needs fast tracking as outputs of these critical services may have had their effect on statistics generated by both active and passive surveillance. The magnitude may vary from miniscule to significant but data should be made available and included in generating inferences. Hence, the need to have the STI information system established as possible backbone for reporting among local governments.
wonders in terms of delaying the country’s early progression to a bigger epidemic. The SHC has provided adequate cover, but still not able to cover all entertainment establishments such as small karaoke bars, massage parlors and spas, as well as the proliferation of freelancers and part time sex workers, those who engage in paid sex when basic necessity strikes. Reaching the MSM has proven to be a real challenge but it has to be addressed. The country’s program is wanting in innovative approaches with acceptable coverage.
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Under the health sector intervention, blood safety is part of the institution-based HIV prevention strategy for the general population, more specifically among blood and blood product recipients. There is a need to ensure that those donating precious blood are free from HIV and other blood borne pathogens. Main strategies supported by GFR6 includes ensuring the donor population to be low or no risk and HIV screening in a quality assured manner of blood units collected prior to transfusion. The remarkable success in organizing the blood donor recruitment process in selected sites showed a lot of promise and is bound for further expansion. The newly organized Donor Recruitment of the Philippines, Inc. and the series of advocacy events to ensure sustained actions helped the National Voluntary Blood Services Program in propagating the concept of voluntary nonremunerated blood donation. Support to the centralization of testing, processing and distribution of blood units is one of the main activities under the blood safety component. GFR6’s support in the provision of test kits for anti-HIV, HBsAg, anti-HCV, malaria and syphilis and complementary human resources and minor equipment and blood transport systems.
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Grant Project Coordination and Management
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The Bureau of International Health Cooperation (BIHC) provides grant management technical expertise for the Project as part of the centralized grant management. The project aligns itself to the policy of sector wide development approach for health (SDAH), which means one basket fund for health to address identified health concerns through agreed medium term plan. The transitional
mechanisms include embedding of project staff in offices involved in grant implementation, monitoring and evaluation and full integration of systems and processes of the government in grant management. Considering the apparent weaknesses previously identified among grants administered by the government, GFR6 was slow in its engagement and in establishment of inherent systems to facilitate grant performance especially in a performance based grant mechanism. Any project is an opportunity to influence national program design and its intervention or a means to develop other resource mobilization activities. In the government set-up, very little opportunity is provided to innovate and in being brave in designing outof-the-box strategies. It is important that the Project further generates enthusiasm to move forward; it should be outward looking but at the same time based on a sound premise of strong foundation for sustainability. As we have learned, tackling or resolving issues as they happen will test the creativity and tactfulness of project implementers in all levels. Some issues may be too huge. Take it one step at a time and observe, document and re-design. Innovate and improve in an interactive manner because the window of opportunity to act is becoming very limited. We are racing against time and the virus is winning if we are to look into the number of recently reported cases.
Global Fund Round 6 HIV Project DIRECTORY OF VCT TRAINED COUNSELORS CAR
JEANETTE CARLOS Med Tech II Southern Isabela General Hospital – Santiago City Tel.# (078) 682-76-87
ELOISA D. QUIZON ERMITA MAY CRUZ Med Tech Caloocan City- Health Department BAGUIO CITY Angeles University Foundation, Inc. Mabini St., ROCKLYN K. BILANGGO D-A Texas St., Villasol Subd., Caloocan Health Department, OWWO-I, OWWA-CAR Angeles City Social Hygiene Clinic Magsaysay Avenue, Baguio City 288-88-11 Loc. 2281 619-4558 TUGUEGARAO CITY MARIA CHERYL P. TUAZON, MD, MPH, MHA Maria Luisa M. Date REGION I - ILOCOS REGION IAN VALDEPENAS Control# GFR6 063 MS III NURSE I City Health Officer MEDI – JRRMC LA UNION Social Hygiene Clinic – Tuguegarao City Health Office San Lazaro Compd. , Valdepenas Apartment, Taft St., corner Tel.# 893-3628 Rizal Avenue, Manila RHODA PLACIDEA G. RILLONLEE Zamora St., Tuguegarao City mcptuaza@yahoo.com 743 8301 loc 1702 NILDA G. Tel.# (078) 846-21-97 OWWO III JULIANA TIMPUG VALENZUELA OWWA RWO I SHEILA VENTURA Nurse III Ground Flour Zambiano Bldg. Nurse II JB Lingad Memorial Josephine G. Diaz Quezon Ave., San Fernando, Cagayan Valley Medical Center Medical Center STI/HIV/AIDS Physician La Union, (078) 846-7269 Regional Hospital Coordinator (072) 700-0330 / 888-4584 Tel.# (095) 961-35-44 Valenzuela City Health Office JOSEPHINE CHUA Poblacion II, Malinta St., LAOAG CITY City Health Office TYREL TOLENTINO, MD Valenzuela City Tuguegarao City Medical Officer IV 2920211 loc 218 IMELDA TAMAYO, MD Tel# (078)846-2197 Ospital ng Angeles, Rural Health Physician Angeles City MANILA CITY SHC – Laoag City RUTH CARLA A. BALAUAG City Health Office, Brgy 10, Tupaz St., FWO, RWO2 JENIFFER A. MORALES KRISTINE JOYCE ARCE Laoag City 2900 OWWA Tuguegarao City OWWOI, OWWA PHN Telefax: (077)772-0289 078-8441575 Dolores City, San Fernando, SHC-City of Manila Pampanga cutie_khriz@yahoo.com ALMEIDA INVENCION Susan T. Daran, DMD (048)860-6029 NURSE III, HEPO STI /NASPCP Coordiantor CHRISTINE MARY BERNAL Mariano Marcos Memorial CHD Region II Rodolfo G. Cabungcal PHN III Medical Center CHD Cagayan Valley PHN – II SHC – City of Manila # 6 San Julian, Bataac, 078 8446585 Rural Health Unit 2 # 175 San Agustin II, Ilocos Norte 2906 Bitas, Arayat, Pampanga Dasmarinas, Cavite almainvencion@yahoo.com Josefina R. Mallillin 0917 854 3388 chit.bernal@yahoo.com (077) 7923133 Nurse Cagayan Valley Medical Center NATIONAL CAPITAL REGION (NCR) NERIZA SALES OVIETA CASTILLO Carig, Tuguegarao City Nurse II Public Health Nurse CALOOCAN CITY San Lazaro Hospital Laoag City Health Office REGION III – CENTRAL LUZON Sta. Cruz, Manila Tupaz St., Laoag City 2900 CECILIA MAGALLOS ASUNCION 046-477-3451 Telefax: (077)772-0289 ANGELES CITY Nurse Diosdado Macapagal Med. CenterLORENA PAPA REGION II CAGAYAN VALLEY LUCIELLE AYUYAO 450 A. Mabini St., Caloocan City Nurses II Control# GFR6 034 San Lazaro Hospital SANTIAGO CITY RHWC – OIC ZENAIDA CALUPAZ, MD Sta. Cruz, Manila SHC – Angeles City MO IV papa_lorena@yahoo.com FRANCISCA MANAGILOD 1-20 Cristina Drive, SHC-Caloocan City Midwife Villa Teresa Subd., Angeles City Mabini St., Caloocan Health MARISSA CABRERA SHC – Santiago City Tel.# 3222479 Department, Social Hygiene Clinic Social Welfare Officer I San Andres, Santiago City zenaida.calupaz@yahoo.com San Lazaro Hospital TERESITA SIGUA 288-88-11 Sta. Cruz, Manila TRINIDAD ESTEBAN HEPO III Loc. 2281 046-477-3451 Midwife SHC-Angeles City SHC-Santiago City Cristina Drive, Villa Teresa Subd., NERISA BELLO ALICE MARTINEZ San Andres, Santiago City Angeles City Med Tech II Nurse (045) 8933628 SHC-Caloocan City San Lazaro Hospital VILMA VILLAMIN A. Mabini St., Sta. Cruz, Manila City Med Tech FERLIN TABIOS Caloocan Health Dept., 046-477-3451 Santiago City Health Office Midwife Social Hygiene Clinic TriDev Specialist Foundation, Inc. zenaida.calupaz@yahoo.co JUDITH SALAZAR MILDRED BILGERA 2086 Puri St., Malabanias, 288-88-11 loc. 2281 Chief Med Tech Nurse Angeles City 361-5716 Jose Fabella Memorial Center Santiago City Angel22_fae@yahoo.com 324-5020 Manila City Health Office s t ep s o u t p a c in g t h e e p i d e mi c
Effective Linkages in Ensuring HIV Safe Blood Supply
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EDNA MEDALLON Med Tech III Blood Bank Sextion Jose Reyes Memorial Medical Center 740-02-46
RICHARD SEÑERES CONSULTANT NURSE – RAD OWWA MAIN 144 B DAVID ST., PASAY CITY 551-6648
Jonathan O. Peralta HEPO/Nurse East Avenue Medical Center East Avenue, Quezon City Marilyn C. Barza Medical Officer VII, Public Health Unit East Avenue Medical Center East Avenue, Quezon City 928 06 11 local 288
PUERTO PRINCESA, PALAWAN EUNICE RINA HERRERA, MD Medical Office IV Puerto Princesa City City Health Office
Jennifer V. Rabang Medtech II Ospital ng Palawan 220 Malvar St., PEDRO MARIO S. MAGUIGAD Puerto Princesa City WELFARE OFFICER III ANA LIZA MILAY OWWA – Regional Operations Katherine Rose I. Sotomayor 048 4348339 local 247 Med Tech II Coordination Service (ROCS) Social Welfare Officer I Blood Bank Section CORON, PALAWAN Buendia Avenue, Pasay City East Avenue Medical Center Jose Reyes Memorial Medical ALLAN GUITAPAN, MD 551-1134 East Avenue, Quezon City Center Municipal Health Officer 928 0611 local 260 740-02-46 Coron, Palawan Municipal REA J. ESTRADA Health Office Rural Health Center, OWWO IV/Currently Training MANDALUYONG CITY CHRISTINE VILLAROMAN Coron, Palawan Coordinator of HRMDD Medical Officer III alanguintapan@yahoo.com OWWA-HRMDD EVILLA P. PAGAL Dermatology Department 551-6652 Family Planning Counselor Jose Reyes Memorial Medical BICOL REGION Friendly Care Foundation Inc. Center REGION V MA. MINERVA C. ELIGIO-PAISO 710 Shaw Blvd. 740-02-46 ITO-II Mandaluyong City LEGASPI, BICOL 722 29 68 Talitha Lea V. Lacuesta, MD OWWA 8917601-24 MO III KAY T. RAMIREZ Luis R. Garcia Jr. San Lazaro Hospital OWWO-II JOYCE J. DALISAY Medical Director AIDTMD – 2nd Flr OWWA RWO5 EA III Friendly Care Foundation Inc. 732 3776 to 78 local 189 ANST Bldg., Washington Drive, Planning and Programs 710 Shaw Blvd. Legaspi City Development Division Mandaluyong City 481-4503; 481-4562; 820-4855 OWWA 722 29 68 Melizza R. Bruza Madeline DL Ranola, MD 834-0089 Nurse I MS III REGION IV San Lazaro Hospital Bicol Regional Blood Center QUEZON CITY Quiricada St., Sta. Cruz Manila DOH – CHD V, Legaspi City LAGUNA LEGASPI SUZETTE ENCISA, MD Jennet D. Avendan 052-4830286 MO IV MARICYNNE L. PENIERO Nurse SHC-Bernardo OWWO II San Lazaro Hospital REGION VI Bernardo Social Hygiene Clinic, OWWA RWO IV A Sta. Cruz, Manila WESTERN VISAYAS QCHD, Unit 1-3 Penthouse Bldg., 732 3776 – 79 local 212 Quezon City Chipeco Avenue., Brgy. Halang, ILOILO CITY Calamba City, Laguna May Gabaldon ADORAIDA BONDOC (049) 502-2866 OB – GYN – IDS ODETA VILLARUEL, MD PHN II 834-3726 UP PGH SHC Physician Quezon City Social Hygiene Clinic Iloilo City Social Hygiene Clinic, Quezon City PUERTO GALERA, Flora Petrache- Marin Iloilo City ORIENTAL MINDORO Medical Officer III,PPMD, Head (033) 320-81-51 IRMA PAGULAYAN San Lazaro Hospital PHN II MARIVIC GONZALES Quiricada St., Sta. Cruz, Manila RAZEL PORTUGALETE Quezon City Health Department Midwife 732 3776 local 148 SHC Nurse Quezon City SHC – Puerto Galera Iloilo City Social Hygiene Clinic, Palangan, Puerto Galera, PASAY CITY Iloilo City RUTH ROSELYNN C. VIBAR Oriental Mindoro (033) 320-81-51 OWWO V/ OIC, (043) 442-0182 JOAN CARLOTA RANIESES, MD Program Services Div. nanranieses@yahoo.com Susana N. Tizon OWWA RWO IV – B MARINEL CARINGAL 551-4180 MS II BEN-LOR BLDG. PHM, Eastern Visayas Medical Center 1184 Quezon Avenue, Q.C Rural Health Unit, MARIE PIERRE PARLADE Abeto Street, Mandurriao, Iloilo 376-2051 Social Hygiene Clinic PHN 053 321 3131 Puerto Galera, Pasay City – Social Hygiene Clinic LEVIN T. GABUTAN Oriental Mindoro # 118 Chateau Verde, BACOLOD CITY OWWO III (043) 442-0182 Valle Verde I, Pasig City OWWA MAIN 551-4180 Ma. Veronica Oberio 5-A Arayat Street, VIOLETA REYES Fax#: 831-8201 Med tech at Bacteriology Section Cubao, Quezon City Nurse III, RHU Corazon Locsin Montelibano 833-0113 Puerto GaleraMA. VICTORIA G. DEMINGOY Memorial Regional Hospital Municipal Health Center OWWO IV, OWWA MAIN 034 7070284 ROSALYNE R. LAVIN Legal Office OWWO IV REA J. ESTRADA B3L5P9 Dasma, GC, Nenita A. Garcia OWWA-NCR Satellite Office OWWO IV/ Salawag, Dasma Cavite Pharmacist V (POEA) Currently Training 551-66-38 Corazon Locsin Montelibano 25-A Bawa St., NIA Village, Coordinator of HRMDD Memorial Regional Hospital T. Sora, Q.C. HRMDD MALVIN NIÑO R. SANGCO Bacolod City 744-4151; 7444153 OWWA ADMIN STAFF I 707 0278 551-6652 OWWA – RAD
REGION VII CENTRAL VISAYAS CEBU CITY LILIOSA BATIANCILA Med Tech/ Clerk III/ In charge of issuance of health card to CSW-Clerk III Social Hygiene Clinic SHC – City Health Dept., Genera Maxilano St., Cebu City, 6000 liliosa52@yahoo.com 022-3659962 Regional OWWA MA. VENIDEZ GAMALE-DAYO OWWO I /I.O OWWA – RW07 Cebu City 032-2543199 ALLEN J. ARROYO OWWO I OWWA RWO 6 205-206 AJL Building, Gen. Luna St., Jaro, Iloilo City 337-4484 5091075 MA. VENIDEZ GAMALE-DAYO OWWO I /I.O OWWA – RW07 Cebu City 032-2543199 REGION VIII EASTERN VISAYAS TACLOBAN MARY CATHERINE O. PASTOR OWWO II OWWA RW08 DOLE Cmpd. Trece Martirez, Tacloban (053) 3214376 523-0315 Lyn L. Verona MS II Chair Eastern Visayas Medical Center Tacloban City 321 5717 REGION IX ZAMBOANGA PENINSULA ZAMBOANGA MARY JANE FRANCISCO RHWC – Outreach Worker (Midwife) SHC – Zamboanga City Petit Barracks, Zone 4C, City Health Office Zamboanga City NIDZMAR USMAN Outreach worker (RN) SHC-Zamboanga City Petit Barracks, Zone 4C, City Health Office Zamboanga City nidzmarusman@yahoo.com
MA. CHRISTINE LIM SHC Nurse City Health Office Zamboanga City DR. MILA FERNANDEZ Volunteer Zamboanga City Heath Office Jay Ann Villanueva Nurse CHO Pagadian City Zamboanga del Sur 0927 416 7078
Rosita G. Artos Medical Social Worker / HACT Member Davao Medical Center Bajada, Davao City (082) 227 – 2731
Maria Lourdes Talens – Cubillan MO IV Caraga Regional Hospital Surigao City 086 826 2459
Imelda M. Mallorca Clinical Psychologist Davao Medical Center JP Laurel Avenue, Davao City 0916 3809695
EVAGRIA CRISMUNDO Nurse III SHC – Butuan City PGB Libertad, Butuan City evagriac@yahoo.com 341-1953 085-3423432
REGION XII SOCCSKSARGEN
Joey M. Quipot PHN II FP Coordinator, Designate Zamboanga del Sur City Heath, City Hall Complex B. Aquino St., Pagadian City, Zamboanga del Sur 062 2144420
GENERAL SANTOS CITY
REGION X NORTHERN MINDANAO
Eric Dennis L. Estrabon Med TechAssit. In Blood Bank YOLANDA H. FABRE & Serology Sect OWWO III General Santos Doctors Hospital, Inc. OWWA – CARAGA National Highway, Gen San City Butuan City (083) 552 3141 local 127/167 815-1894
cagayan de oro Corazon B. Mata HACT Coordinator Northern Mindanao Medical Center Capitol Compound, Cagayan de Oro City 08822-725 735 local 107 RHONA Z. FAHIGAL OWWO III OWWA RWO 10 Cagayan de Oro City CDO 08822-729587 REGION XI SOUTHERN MINDANAO DAVAO CITY JORDANIA RAMITERRE, MD MO-VI SHC-Davao City SHC-RHWC City Health Office Magallanes St., Davao City pram07@yahoo,com 222-4187(RHU Davao) ROSEMARIE G. LUNTAO OWWO III OWWA – RWO XI Door E-6, CAM Bldg., Monteverde St., Davao City (082) 221-8593 / (082) 227-9536 Felipa A. Banate Social Welfare Office III Davao Regional Hospital Apokon, Tagum City 400 3653 Telesfora A. Hinay Medical Technology III Davao Regional Hospital Apokon, Tagum City 084 400 4023
JUMAMA UMADHAY, MD MO III General Santos Hospital Blk 17 Lot 7 Ph3A Dona Soledad Subd. General Santos City Tel.# (083) 3051510
Dulce Aurora N. Ariston Med Tech General Santos City Health Office 083 554 1637; 083 302 3922 SOUTH COTABATO REGIONAL OWWA KRISTINE MARIE H. SISON ADMIN ASSISTANT OWWA – XII Koronadal City 083-5200205 Rosalie O. Luces Nurse II Cotabato Regional & Medical Center Sensuat Avenue, Cotabato City 064 4212340 Elsie B. Legara Nurse V, STI HIV AIDS Coordinator DOH – CHD 12 SOCCSKSARGEN Noraina S. Arumpac Social Welfare Officer I Cotabato Regional & Medical Center Sinsuat Aveue, Cotabato Ctiy 9600 CARAGA REGION XIII BUTUAN CITY YOLANDA H. FABRE OWWO III OWWA – CARAGA Butuan City Fernando S. Aliguay Nurse II Caraga Regional Hospital Surigao City (086) 826 0497815-1894
DOROTHY GUNDAYA Med Tech Butuan City Health Office Butuan City 341-1953 085-3423432 AUREA ENCABO Butuan City Health Office Butuan City
ARMM MARILOU M. SUMALINOG OWWO III OWWA- ARMM Bansil Bldg., Sinsuat Avenue, Cotabato City (064) 421-7237
DIRECTORY OF VCT TRAINED COUNSELORS
1755 M. Santiago Ext. F. B. Harisson, Pasay City 5516648
PNAC SUSAN GREGORIO, MD PNAC Secretariat PNAC 3rd Floor, Bldg 15, DOH, Tayuman, Manila docsaprace@yahoo.com 743-0512 GFR6 MARK ANTHONY ANOSO GFR6-HIV 1st floor, Bldg. 14, DOH, Sta. Cruz, Manila Tel.# 743-8301 local. 1725 Tel. # 495-01-49 SYLVESTRA FREITA P. BAUTISTA, MD SIO GFR6-HIV 1st floor, Bldg. 14, DOH, Sta. Cruz, Manila beyaf@yahoo.com Tel.# 743-8301 local. 1725 Tel. # 495-01-49 HELEN D. PAANO GFR6-HIV 1st floor, Bldg. 14, DOH, Sta. Cruz, Manila Tel.# 743-8301 local. 1725 Tel. # 495-01-49
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DIRECTORY OF VCT TRAINED COUNSELORS st e p s o u t p a c in g t h e e p i d e m i c
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ZORAHAIDA CINCO Med Tech III Manila Social Hygiene Clinic
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