Low Rate of AIDS Virus in Philippines Is a Puzzle

By SETH MYDANS

NY Times 4/20/03

MANILA -- Public health officials say they are stumped by a paradox in the Philippines, where a very low rate of condom use and a very low rate of H.I.V. infection seem to be going hand in hand.

AIDS-prevention efforts often focus on the use of condoms, but they are not widely available here -- and are mostly shunned -- in this conservative Roman Catholic country.

Without that first line of defense, experts can only guess at the reasons for the low infection rate. No more than about 10,000 people are believed to be infected with H.I.V., the virus that causes AIDS, in a population of 84 million, and the relatively low rate is not thought to be a case of underreporting.

"It's quite perplexing," said Zahidul Huque, who heads the United Nations team group on H.I.V./AIDS for the Philippines. "We've been talking about it a lot and frankly, we don't know why it's low. The potential for an explosion is there."

This is particularly so because the Philippines is far from being a country with closed borders. About one-tenth of the population works overseas, all of them potential carriers of disease whenever they visit home.

Experts say a lucky combination of factors may for the moment have slowed the arrival of an epidemic, including a low ratio of customers to sex workers, low rates of certain other sexually transmitted diseases and limited intravenous drug use.

"There is no strong, clear-cut factor that will tell us, this is the reason why," said Jean-Marc Oliv?the World Health Organization representative for the Philippines. "I think it's a number of different factors adding up. I think they are lucky, but that's not at all the way to control AIDS."

As of January, government figures showed that just 1,810 people had tested positive for H.I.V. The United Nations office on AIDS estimates that the actual number may be closer to 9,400 -- still an extraordinarily low rate of about 0.01 percent.

In Vietnam, for example, with almost exactly the same population, and where the epidemic is still thought to be in its early stages, 130,000 people are infected H.I.V., according to the United Nations.

Conversely, Costa Rica has about the same number of people with H.I.V. and AIDS as does the Philippines. But Costa Rica is just one- twentieth the size of the Philippines, with 3.8 million people.

Another risk factor here is that little is being done to hold back a possible epidemic. The word condom is almost taboo in a country where the Roman Catholic church is both conservative and politically powerful.

"Whenever you talk about condoms it's a little bit difficult," said Dr. Olive. The government has no AIDS-awareness program of its own and restricts the public campaigns of independent family-planning groups.

One result is that in a country where more than half the population is of reproductive age, only 23 percent of sexually active young men say they have ever used a condom. Only 4 percent say they use condoms regularly. Only two out of five sex workers say they use them regularly.

Like other experts, Dr. Olive said the low number of reported infections was not simply the result of poor record-keeping.

"It's not a reporting issue," he said. "It's a real fact that we don't understand really why AIDS infection is so low here in the Philippines."

The most frequently cited reason is that commercial sex workers have fewer partners than their counterparts elsewhere. The average is about four per week, according to a new government survey. Other studies suggest that a relatively low proportion of men frequent sex workers.

Experts say other factors may be the small number of intravenous drug users and a low prevalence of ulcerated sexually transmitted diseases -- like syphilis and herpes -- that facilitate transmission of the AIDS virus. Anal sex also appears to be less common.

Also, most men here are circumcised and there has been speculation in the Philippines and elsewhere that this could be a factor in preventing infection.

In the small city of Angeles, where about 1,600 women work in a thriving red-light district, the director of the health center, Dr. Teresita Esguerra, said a mass screening last year found five women to be infected. Because they cannot afford the drugs needed to slow the progress of the disease, she said, the clinic can do little more than offer them information and advice.

"They are advised to still work, because they have the right to work under Philippine law," the doctor said. "They are properly counseled and properly guided, but we do not advise them to stop working."

She said the women are encouraged to use condoms but complain that their customers often object and that "because of financial reasons" the women do not insist.

So: the safer-sex boyz are shocked, shocked to discover that people aren't getting HIV even though they're not using condoms.

Of course, these same people start having sex later in life, have relatively few partners, and the men who have sex with men among them appear to have less anal sex.

I queried one of the USAID researchers about the Philippines and he quoted as follows from a report he co-authored:

To summarize the factors contributing to the "low and slow" pattern of HIV transmission [in the Philippines]:

• Low levels of multi-partnerism [promiscuity] among great majority of people.

• High age of sexual debut (average age of 18.8 for men; somewhat higher for women).

• Low proportion of men exposed to commercial sex core groups.

• Low levels of ulcerative STDs in high-risk populations. [Ulcerative STDs put you at great risk for HIV.]

• Relatively low level of Sex Worker customer turnover (average of 2-3 per week).

• Near-universal male circumcision prior to age of sexual debut. [Foreskin is very vulnerable to HIV.]

The same report suggested that gays are into anal in the Philippines -- but that section of the report was authored by an American gay man whose "research" consisted of interviewing some transvestite prostitutes and a few gay men of his acquaintance.

Which tells us nothing -- except that he hangs with an unsafe anal crowd.

What's more likely is that men who have sex with men in the Philippines do far less anal and are far less promiscuous than their American peers.

If they're not doing anal, what do you think they're doing?

C2C? Could be.

But in the Philippines, as in Uganda, what we can see is that condoms are not the answer.

Rather, Abstain, Be faithful, and Cockrub -- that is, non-penetrative alternatives -- are carrying the day.

I'll have more to say about the reaction of the safer-sex establishment to this piece of good news later.

For now dudes, just remember

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