hiv awareness research paper in the philippines

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The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023

Affiliations.

1 Hawaii Center for AIDS, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96813, USA.
2 Love Yourself, Inc., Mandaluyong 1552, Metro Manila, Philippines.
PMID: 37235306
PMCID: PMC10224495
DOI: 10.3390/tropicalmed8050258

In the past decade, the Philippines has gained notoriety as the country with the fastest-growing human immunodeficiency virus (HIV) epidemic in the Western Pacific region. While the overall trends of HIV incidence and acquired immunodeficiency syndrome (AIDS)-related deaths are declining globally, an increase in new cases was reported to the HIV/AIDS and ART Registry of the Philippines. From 2012 to 2023, there was a 411% increase in daily incidence. Late presentation in care remains a concern, with 29% of new confirmed HIV cases in January 2023 having clinical manifestations of advanced HIV disease at the time of diagnosis. Men having sex with men (MSM) are disproportionately affected. Various steps have been taken to address the HIV epidemic in the country. The Philippine HIV and AIDS Policy Act of 2018 (Republic Act 11166) expanded access to HIV testing and treatment. HIV testing now allows for the screening of minors 15-17 years old without parental consent. Community-based organizations have been instrumental in expanding HIV screening to include self-testing and community-based screening. The Philippines moved from centralized HIV diagnosis confirmation by Western blot to a decentralized rapid HIV diagnostic algorithm (rHIVda). Dolutegravir-based antiretroviral therapy is now the first line. Pre-exposure prophylaxis in the form of emtricitabine-tenofovir disoproxil fumarate has been rolled out. The number of treatment hubs and primary HIV care facilities continues to increase. Despite these efforts, barriers to ending the HIV epidemic remain, including continued stigma, limited harm reduction services for people who inject drugs, sociocultural factors, and political deterrents. HIV RNA quantification and drug resistance testing are not routinely performed due to associated costs. The high burden of tuberculosis and hepatitis B virus co-infection complicate HIV management. CRF_01AE is now the predominant subtype, which has been associated with poorer clinical outcomes and faster CD4 T-cell decline. The HIV epidemic in the Philippines requires a multisectoral approach and calls for sustained political commitment, community involvement, and continued collaboration among various stakeholders. In this article, we outline the current progress and challenges in curbing the HIV epidemic in the Philippines.

Keywords: AIDS; HIV; Philippines; human immunodeficiency virus; public health.

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The authors declare no conflict of interest. The views and opinions expressed in this article do not reflect the views and opinions of the authors’ affiliations.

Estimated annual new HIV infections…

Estimated annual new HIV infections among individuals 15 years old and above from…

Traditional versus rapid HIV diagnostic…

Traditional versus rapid HIV diagnostic algorithm in the Philippines. Abbreviations: rHIVda: rapid HIV…

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Open Access

Peer-reviewed

Research Article

Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliations Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom, Center for Research and Innovation, School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliations Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Veincent Christian F. Pepito,

Published: May 12, 2020
https://doi.org/10.1371/journal.pone.0232620
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26 Jan 2021: Pepito VCF, Newton S (2021) Correction: Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey. PLOS ONE 16(1): e0246013. https://doi.org/10.1371/journal.pone.0246013 View correction

The prevalence of having ever tested for HIV in the Philippines is very low and is far from the 90% target of the Philippine Department of Health (DOH) and UNAIDS, thus the need to identify the factors associated with ever testing for HIV among Filipino women.

We analysed the 2013 Philippine National Demographic and Health Survey (NDHS). The NDHS is a nationally representative survey which utilized a two-stage stratified design to sample Filipino women aged 15–49. We considered the following exposures in our study: socio-demographic characteristics of respondent and her partner (i.e., age of respondent, age of partner, wealth index, etc.), sexual practices and contraception (i.e., age at first intercourse, condom use, etc.), media access, tobacco use, HIV knowledge, tolerance to domestic violence, and women’s empowerment. The outcome variable is HIV testing. We used logistic regression for survey data to study the said associations.

Out of 16,155 respondents, only 372 (2.4%) have ever tested for HIV. After adjusting for confounders, having tertiary education (adjusted odds ratio (aOR) = 2.15; 95% Confidence Interval (CI): 1.15–4.04), living with partner (aOR = 1.72; 95% CI: 1.19–2.48), tobacco use (aOR = 1.87; 95% CI: 1.13–3.11); belonging to the middle class (aOR = 2.72; 95% CI: 1.30–5.67), richer (aOR = 3.00; 95% CI: 1.37–5.68), and richest (aOR = 4.14; 95% CI: 1.80–5.91) populations, having weekly television access (aOR = 1.75; 95% CI: 1.04–2.94) or internet access (aOR = 2.01; 95% CI: 1.35–3.00), living in a rural area (aOR = 1.87; 95% CI: 1.34–2.61); and being a Muslim (aOR = 2.30; 95% CI: 1.15–4.57) were associated with ever testing for HIV.

Conclusions

The low percentage of respondents who test for HIV is a call to further strengthen efforts to promote HIV testing among Filipino women. Information on its determinants can be used to guide the crafting and implementation of interventions to promote HIV testing to meet DOH and UNAIDS targets.

Citation: Pepito VCF, Newton S (2020) Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey. PLoS ONE 15(5): e0232620. https://doi.org/10.1371/journal.pone.0232620

Editor: Joel Msafiri Francis, University of the Witwatersrand, SOUTH AFRICA

Received: January 31, 2020; Accepted: April 17, 2020; Published: May 12, 2020

Copyright: © 2020 Pepito, Newton. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data for the 2013 Philippine National Demographic and Health Survey Individual Recode are available from the Demographic and Health Surveys Program Website ( https://www.dhsprogram.com/data/available-datasets.cfm )

Funding: The authors have not received specific funding to conduct the analysis; however, they have received financial support from the Ateneo de Manila University School of Medicine and Public Health and the PLOS Publication Fee Assistance Office for the publication fee of the manuscript. These funding agencies did not have a role in the analysis, writing of the manuscript, as well as decision to publish.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Despite the worldwide decrease in the incidence of Human Immunodeficiency Virus (HIV) infections [ 1 , 2 ], the Philippines is currently experiencing a rapid increase in the number of HIV cases [ 2 – 5 ]. For the first seven months of 2019, around 35 new cases of HIV are diagnosed in the country every day. From 1984 to July 2019, there have been 69,512 HIV cases that have been diagnosed in the Philippines; 4,339 (6.7%) of whom are women [ 6 ]. However, HIV statistics in the Philippines are perceived to be underestimates due to Filipinos’ low knowledge and/or stigma associated with HIV testing [ 3 – 5 , 7 , 8 ]. It is estimated that around one-third of all Filipinos who have HIV do not know their true HIV status, despite HIV testing being free in many facilities throughout the country [ 3 ]. From the 2013 Philippine National Demographic and Health Survey (NDHS), only 2.3% of all the female respondents have reported that they have ever tested for HIV [ 9 ].

HIV testing is considered to be among the cornerstones of most HIV prevention and control strategies [ 10 – 12 ]. At the individual level, HIV testing, together with counselling, is an avenue where people can be educated about risky behaviors associated with the disease [ 13 ]. For those who have the disease, HIV testing is the first step into the continuum of care where they can be managed accordingly which will hopefully stop disease progression and transmission [ 12 , 14 ]. From a public health perspective, the greater the number of individuals who will undergo HIV testing, the more accurate the statistics will be for the disease. This will lead to better allocation of resources for public health interventions that will help curb the HIV epidemic [ 3 , 12 ]. For women, HIV testing has an added benefit of possibly preventing mother-to-child transmission of HIV. It is for this reason, together with the increasing numbers of pregnant women diagnosed with HIV and children born with HIV from 2011–16, that the Philippine Department of Health (DOH) has strongly encouraged pregnant women in the Philippines to undergo HIV testing. In relation to this, the DOH has decreed that by 2022, the proportion of people living with HIV (PLWH) who knows their status should be 90% [ 3 ]. This is in-line with the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, which stipulates that by 2020, “90% of all PLWH will know their true status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression” [ 15 ].

Given the importance of HIV testing among women, studies identifying its determinants have been carried out before. These determinants can be classified into socio-demographic determinants (e.g., age, educational attainment, address, religion, marital status, socio-economic status, employment, media exposure, and number of children) or HIV-related determinants (e.g., sexual behaviors, knowledge on HIV, perceptions on HIV testing, consumption of intoxicants, and having talked to mother or female guardian about HIV) [ 16 – 21 ]. Other determinants of HIV testing include having a dysfunctional relationship with their spouse/partner, tolerance of domestic violence, experiencing stigma, media exposure, number of lifetime sexual partners, having talked to mother/female guardian regarding HIV testing, ever pregnant, and exposure to public health interventions regarding HIV [ 16 , 17 , 22 ]. Two reviews emphasized that there are a host of social, institutional- and policy-level factors, often not considered in most observational studies, which may also act as barriers or enablers of HIV testing [ 23 , 24 ]. However, despite the numerous studies cited on HIV testing among women worldwide, and despite the HIV epidemic in the Philippines, there were no studies focusing on HIV testing among Filipino women in published literature. This is ostensibly due to the low proportion of cases of women with HIV in the country [ 6 ]. This implies that women could have been left behind in the response to the HIV epidemic in the country.

In order to address this gap and in order to craft interventions to encourage Filipino women to undergo testing, this analysis aims to identify the determinants of HIV testing among Filipino women. The results of this study could serve as the first step in the implementation of interventions to promote HIV testing among Filipino women to help meet DOH and UNAIDS targets.

Study design, setting, and participants

This study is a secondary analysis of the 2013 Philippine NDHS women’s individual recode data. The survey used a stratified two-stage sampling design with the 2010 Philippine Census of Population and Housing as sampling frame. The first stage sampling involved a systematic selection of 800 sample enumeration areas all over the country, distributed by urban/rural regions, to ensure representativeness. In the second stage, 20 housing units were randomly selected from each enumeration area using systematic sampling. All households in the sampled units were interviewed. From each household, women aged 15–49 were interviewed. The interviews were carried out all throughout the Philippines from August to October 2013. Other details of the sampling method for the 2013 Philippine NDHS can be found in its report [ 9 ].

Data collection and study variables

The 2013 Philippine NDHS utilized a paper-based, pre-tested interview schedule to collect data on a wide range of socio-demographic, economic, knowledge on some health issues, health practices, fertility and childbirth, immunization of children, health insurance, domestic violence, women’s empowerment, and other variables from a nationally-representative sample. A copy of the interview schedule can be seen on the final report of the 2013 Philippine NDHS [ 9 ].

Despite the multitude of variables collected in the study, only variables that are deemed to influence HIV testing were included in the analysis. The exposure variables for this study were: Age; educational attainment; civil status; condom use; consistent condom use; condom access; use of any traditional contraception method; tobacco consumption; age of husband/partner; educational attainment of partner; HIV knowledge, wealth index; address; tolerance to domestic-based gender violence; women’s empowerment score; number of children; religion, reading newspapers; weekly access to television, radio, newspapers, and internet; age of first sexual intercourse, and knowledge of condom source. The outcome variable for this study is HIV testing. A description of how the variables were operationally defined, as well as how they were coded are described in an Appendix ( S1 Appendix ).

To minimize observer bias, data collectors for the 2013 Philippine NDHS underwent a two-week training in administering the data collection tool. Furthermore, systematic random sampling was used to ensure representativeness. Moreover, data collectors visited the respondents at home repeatedly to ensure that the randomly selected respondents were interviewed, instead of replacing them with whoever is convenient, thus minimizing selection bias. To minimize encoding errors, encoders underwent training in using the data entry program created specifically for this NDHS [ 9 ].

Data management

Once permission was obtained from the NDHS data curators, the Individual Recode dataset of the 2013 Philippine NDHS was downloaded from the DHS website [ 25 ]. After this, the dataset was cleaned. In cleaning the dataset, new variables were generated from each variable that were included in the analysis. These new variables were cleaned and analysed to preserve the original data as much as possible. Inconsistent responses were considered as “no data” as the original responses of the respondents could no longer be obtained.

Some variables (e.g., employment status, marital status, etc.) were recoded to ensure that there were sufficient observations for each strata. Other variables (e.g., tobacco consumption) were recoded to ensure that the baseline stratum would have more observations, thus ensuring more stable estimates than if the current coding was used. Quantitative age variables were transformed into age brackets [e.g., 15–19, 20–24 years old, etc.] so that the effect of having similar ages on the outcome could be studied. The midpoint was assigned as the ‘score’ for each age group [e.g., the score ‘17’ were assigned to those who were aged 15–19; the score ‘22’ were assigned to those who were aged 20–24, etc.]. Condom use variables were recoded such that the baseline would be those who have never had sexual intercourse. Those who have used condoms consistently would also be noted with this variable. Similarly, variables on employment status or educational attainment of partner were recoded such that the baseline would be those who do not have partners at present.

Score variables (e.g., HIV knowledge score, women’s empowerment, tolerance to domestic violence) were aggregated from many questions. HIV knowledge score were derived from the following questions: [ 1 ] Ever heard of AIDS; [ 2 ] Reduce risk of getting HIV: Always use condoms during sex; [ 3 ] Reduce risk of getting HIV: have one sex partner only, who has no other partners; [ 4 ] Can get HIV from mosquito bites; [ 5 ] Can get HIV by sharing food with person who has AIDS; [ 6 ] A healthy looking person can have HIV; and [ 7 ] Can get AIDS by shaking hands. Tolerance to domestic violence score was aggregated from the following questions: [ 1 ] Beating justified if wife goes out without telling husband; [ 2 ] Beating justified if wife neglects the children; [ 3 ] Beating justified if wife argues with husband; [ 4 ] Beating justified if wife refuses to have sex with husband; [ 5 ] Beating justified if wife burns the food. Women’s empowerment score was derived from the following questions: [ 1 ] Who decides on your healthcare; [ 2 ] Who decides on large household purchases; [ 3 ] Who decides on daily household purchases; [ 4 ] Who decides on visits to family or relatives; and [ 5 ] Who decides what to do with money husband earns. For the HIV knowledge score questions, one point will be given for each correct answer, while no points will be given for incorrect or ‘don’t know’ answers. For tolerance to domestic violence questions, one point will be given for each ‘no’ answer while no points will be given for ‘don’t know’ answers. For each women empowerment questions, two points were given for each ‘respondent only’ answer, one point were given for each ‘respondent and partner’ answer and no points were given for each ‘other answers’. The points from each question were added to come up with the HIV knowledge score, women’s empowerment score, and tolerance to domestic violence score. A respondent with missing data in any of the questions that make up a score will not have an aggregate score. The aggregated score was left as a continuous variable so that the effect of a one-point increase in these variables on HIV testing can be quantified.

All data management and analyses were carried out in Stata/IC 14.0 [ 26 ].

Data analysis

After preliminary cleaning, the dataset was declared as survey data and the sampling weights and strata (i.e., urban and rural, regions) were defined. All subsequent analyses, if applicable, were weighted. The distributions of each variable were determined by noting the respective histograms and measures of central tendency for continuous variables, and frequencies and proportions for categorical variables. For the descriptive analyses, weighted means and proportions will be shown; however, counts, medians, and modes will not be weighted.

The association of the exposures with HIV testing were examined using Pearson’s χ 2 test (for categorical exposure variables), adjusted Wald test (for normally-distributed continuous exposure variables), or the Wilcoxon rank-sum test (for skewed continuous exposure variables). The Pearson’s χ 2 test and the adjusted Wald test will be weighted; however, the Wilcoxon rank-sum test is not weighted because of the lack of applicable non-parametric statistical tests for weighted data. Those with missing data were not included in computing for the p-values for these tests. Crude odds ratios (OR) for each of the associations between exposure and the outcome were estimated using logistic regression for survey data.

Once the crude OR for this association were obtained, variables that might be in the causal pathway of other variables were excluded from the analyses. The remaining variables were then classified into whether they are proximal or distal risk factors. Proximal risk factors (PRFs) can be defined as factors that are thought to be closer to the outcome in a causal diagram, while distal risk factors (DRFs) were factors that were farther from the outcome and may indirectly contribute to causing it [ 27 ]. After this, a variable was generated to indicate respondents who do not have missing data for any of the remaining variables. Multivariate analyses were only carried out for respondents who have complete data for all of the variables of interest. To determine the order in which variables will be introduced into the final model, logistic regression for survey data was used to assess the effect of each PRF, adjusting for the DRFs with a p≤0.20 in the bivariate analyses. Adjusted OR of each PRF, as well as corresponding p-values were noted.

Logistic regression for survey data was used in the analyses of these associations. In building the final model for the determinants of HIV testing, DRFs were added into the model with the variable having the smallest p-value added first, then the second smallest p-value added second, and so on, until all DRFs with p≤0.20 from the bivariate analysis are in the model. After this, PRFs were added to the model starting with those with the smallest p-values in the analysis adjusting for DRFs until all the PRFs with p≤0.20 in the analyses adjusting for DRFs were added, or the maximum number of parameters was reached. While p-value cutoffs are not to be blindly followed in studying causal relationships in epidemiology, they may aid in variable selection to prevent models from being too overly-parameterized [ 28 , 29 ]. The maximum number of parameters for the final model are contingent on the effective sample size for the multivariate analysis, taking into consideration the ‘rule of 10’ events per parameter estimated [ 30 ].

At any point in the building of the final model, test for departure from the linearity assumption was carried out by observing the stratum-specific ORs, and running the contrast command in Stata once a quantitative ordinal variable (e.g., age group, wealth index, etc.) was added to the model. Since the midpoint of each age group was used as the ‘score’, parameters of a common linear trend would not only estimate the common linear effect of the age groups on the outcome, but also the common change in effect on the outcome per unit change in age [ 31 ]. In addition, model estimates were also observed for signs of multicollinearity or separation every time a variable is added. Variables with problematic estimates may be excluded from the analysis.

Considering that assessing effect measure modification (EMM) was not among the objectives, and that Mantel-Haenszel methods cannot be used in the analysis of survey data [ 32 ], no assessment of EMM for any of the variables was carried out. Furthermore, no observations were deleted from the analyses to ensure that standard errors can be computed correctly [ 33 ]. Missing data were handled by presenting them in the univariate analyses and excluding respondents who have missing data in any of the variables of interest in the multivariate analyses.

Despite making several hypothesis tests, the level of significance was not adjusted. Instead, it was maintained at 0.05 all throughout the analysis as it is safer not to make adjustments for multiple comparisons in the analysis of empirical data to minimize errors in interpretation [ 34 ].

The 2013 Philippine NDHS has received ethical approval from ICF Macro Institutional Review Board (Project No.: 31561.00.000.00) dated July 1, 2010. This analysis has received ethical approval from the London School of Hygiene and Tropical Medicine MSc Ethics Committee (Reference No.: 15014).

The 2013 Philippine NDHS collected data from 16,437 Filipino women aged 15–49 years old. Interviews were completed for 16,155 individuals, with a 98.3% response rate. Except for counts, ranges, and non-parametric results, subsequent statistics shown are all weighted.

Only 372 (2.4%) respondents have ever tested for HIV. Most of the respondents finished secondary education, are married, do not use condom, do not use traditional contraception, are Roman Catholic, and have weekly television access. However, a substantial proportion of respondents have no data on condom access, age group of partner, and educational attainment of partner. This is predominantly because they have not had any sexual partners yet and/or have not had a partner at present. Among the categorical exposure variables and without adjusting for confounding, age of respondent, educational attainment of respondent, employment status of respondent, civil status, age at first intercourse, condom use, condom access, knowledge of condom source, usage of traditional contraception, tobacco use, educational attainment of partner, socio-economic status, and newspaper, television, and internet access were found to be associated with having ever tested for HIV ( Table 1 ). All of these factors are positively associated with having ever tested for HIV, except for condom access and condom source. The negative association of these latter two variables with HIV testing denote that not having condom access and not knowing a condom source is a determinant of never testing for HIV.

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https://doi.org/10.1371/journal.pone.0232620.t001

Around 38% of the respondents have never had sexual intercourse, and majority do not have more than one sexual partner throughout their lifetime. Imputed age at first intercourse ranged from 7 to 47 years old. There are 5,891 (37.0) respondents who do not have children, and around 4,480 (28.3%) having only one or two children. Most of the respondents have a high (≥5/7) HIV knowledge score, have a high women empowerment score (≥6/10), and a low tolerance to domestic violence. The distributions of the number of lifetime sexual partners and HIV knowledge score were found to differ between those who were tested for HIV and those who were never tested for HIV. Despite these, none of the quantitative exposure variables had shown a strong evidence of association with HIV testing ( Table 2 ).

https://doi.org/10.1371/journal.pone.0232620.t002

For the multivariate analysis, distal risk factors that have a p≤0.20 in the cross-tabulations are age of respondent, highest educational attainment of respondent, employment status, civil status, tobacco use, highest educational attainment of partner, socio-economic status, domicile, religion, newspaper access, television access, and internet access. Proximal risk factors that have a p≤0.20 in the cross-tabulations are age at first intercourse, condom use, condom access, knowledge of condom source, traditional contraception, number of children, number of lifetime sexual partners and HIV knowledge score. However, because there is collinearity between knowledge of condom source and condom access, and because the latter has a lot of missing data, it will not be among the variables that will be considered in the analysis. Only 8,578 (53.2%) respondents have complete data for the variables that are considered in the multivariate analysis. Out of these, 243 (2.8%) have underwent HIV testing ( Table 3 ).

https://doi.org/10.1371/journal.pone.0232620.t003

In building the final model, tests for linear trend were run for age of respondent, age at first sexual intercourse, and socio-economic status. Age of respondent (p = 0.27) and age at first sexual intercourse (p = 0.92) did not show evidence of deviation from a linear trend, but there is an evidence for deviation of a linear trend for socio-economic status (p<0.01), which meant that stratum-specific ORs were shown for socio-economic status instead of common ORs.

After adjusting for other variables, having tertiary education (adjusted odds ratio (aOR) = 2.15; 95% Confidence Interval (CI): 1.15–4.04), being unmarried but living together with partner (aOR = 1.72; 95% CI: 1.19–2.48), tobacco use (aOR = 1.87; 95% CI: 1.13–3.11); belonging to the middle class (aOR = 2.72; 95% CI: 1.30–5.67), richer (aOR = 3.00; 95% CI: 1.37–5.68), and richest (aOR = 4.14; 95% CI: 1.80–5.91) populations, having weekly television access (aOR = 1.75; 95% CI: 1.04–2.94) or internet access (aOR = 2.01; 95% CI: 1.35–3.00), living in a rural area (aOR = 1.87; 95% CI: 1.34–2.61); and being a Muslim (aOR = 2.30; 95% CI: 1.15–4.57) were associated with higher odds of HIV testing among Filipino women aged 15–49.

Only around 2% of Filipino women have had HIV testing throughout their lifetimes, implying that there is still substantial work to be done in promoting HIV testing to Filipino women to meet DOH and UNAIDS targets. Women’s educational attainment, civil status, tobacco use, socio-economic status, television and internet access, domicile, and religion showed strong evidence of association with HIV testing. This information could be used to guide the development of interventions to promote HIV testing among Filipino women.

These associations were similar to the findings of other studies. Specifically, there seems to be an increasing propensity for HIV testing among more educated or wealthier respondents, regardless of gender [ 7 , 16 ]. A study conducted in the United States also found that smoking was found to be strongly associated with HIV testing. Accordingly, the said study explains that smokers might be more likely to undergo HIV testing because being a smoker is associated with risky sexual behaviors and/or drug use, the latter two are known independent risk factors for HIV [ 35 ]. Due to certain religious taboos, HIV testing remains very low among some religious groups in the country. However, the odds of HIV testing are highest among Muslims. While there are no studies explaining this phenomenon in the Philippines, a study conducted in Malaysia explains that in their country, Muslim religious leaders were supportive of HIV testing because it provides a protective mechanism in line with Islamic teachings [ 36 ]. The specifics of the association between media exposure and HIV testing was examined in detail in this study and was found to be similar to those that are found in other settings [ 16 , 17 ]. Frequent exposure to television and Internet also increases the probability of exposure to HIV information, education, and communication (IEC) campaigns promoting HIV testing disseminated through these forms of media, thus promoting HIV testing.

There were also differences in the findings of this study with what has been published in literature. In this analysis, older individuals were found to be more likely to have undergone HIV testing than younger respondents, but this trend is the exact opposite of what was found in Burkina Faso, where older women were found to be less likely to test than younger ones. The same study in Burkina Faso found that living in a rural area inhibits HIV testing [ 16 ], while this analysis found that those from rural areas are more likely to have undergone HIV testing as compared to those from urban areas. Without adjusting for confounders, we found several factors to be associated with HIV testing in this analysis, but a secondary analysis of data collected on 2003 from Filipino males show that only HIV knowledge is strongly associated with getting HIV test result [ 7 ].

While consistency of results across populations or circumstances strengthen evidence for causation [ 37 ], its absence does not necessarily mean that results are no longer valid nor useful. A possible reason explaining the differences in the effect of age on HIV testing is the difference in how age was handled in the analyses. This study grouped respondents on five-year age groups, while other studies grouped respondents on 10-year groups [ 16 , 22 ]. Another possible reason for the differences between the findings of this study and others is that the populations and contexts on the studies being compared might be inherently different. Differences in social, economic and political context underpinning HIV epidemiology and response should not be ignored in comparing findings from different settings [ 38 – 41 ]. Findings from the older study involving Filipino males may differ from the current study due to gender differences. Secular changes may also explain why results differed between the previous study and this analysis [ 7 ].

The study presents several salient points of concern. First, the prevalence of HIV testing remains to be very low. Second, the association of socio-economic status and highest educational attainment with HIV testing highlights inequities in access and utilization of HIV testing services, despite it being offered for free in government facilities. This is ostensibly explained by low awareness of HIV testing, and an even lower awareness that it is offered for free [ 3 ]. Third, the Philippine DOH has made significant strides to encourage HIV testing among pregnant women [ 3 ], but as the results show, number of children was not found to be associated with HIV testing which highlight the need to do more in promoting HIV testing among pregnant women. Fourth, the lower odds of testing among those who are from urban areas are worrying because urban centers in the Philippines are where HIV cases are rapidly rising.

Despite these worrying conclusions, the study is best interpreted with its limitations in mind. The exclusion of almost half of the respondents in the multivariate analysis due to missing data underlines the possibility of selection bias. The respondents who were excluded were mostly those who do not have partners, or have never had sexual intercourse, because these respondents did not have data for educational attainment of partner. The exclusion of these respondents also meant that the baseline for the condom use variable are no longer those that have never had intercourse, as in the univariate analysis, but those who did not use condom in their last intercourse. This also meant that the baseline for the civil status variable are now those who are married, instead of those who were never in union as in the univariate analysis. A separate model was considered for those who do not have partners or those who never had sexual intercourse, but the very low proportion of respondents who tested for HIV for these populations meant that such a model might have low statistical power. Not to mention, those who never had sexual intercourse is deemed to have low risk in developing HIV as HIV is mostly transmitted sexually here in the Philippines. Given this, it should be kept in mind that the findings of this analysis may only be generalized to those who have already had sexual partners.

Alternative variable selection strategies emphasize that all known confounders should be controlled for in the model [ 42 ]. From this line of reasoning, there would still be residual confounding as we have not controlled for variables either because they were not collected in the original dataset (i.e., social support, drug use, etc. and other factors working beyond the individual level), or were excluded due to the specified p-value cutoff in the Methodology. However, controlling for all known confounders might lead to overly parameterized models, especially that our proportion of HIV testers is very low. It is for this reason that p-value cut-offs were used to select variables to include in the model. Even the multivariate model itself fails to meet the ‘rule-of-10’, having estimated 29 parameters on 243 events (i.e., people who tested for HIV), giving us 8.4 events per parameter. However, simulation studies have shown that the ‘rule-of-10’ can be relaxed to up to five events per parameter without expecting issues in chances of type-I error, problematic confidence intervals, and high relative bias [ 30 ].

Cross-sectional studies such as this analysis are especially susceptible to reverse causality, especially for data that may vary with time. This is often a problem for this study design as both exposure and outcome data are collected simultaneously. This prevents ascertainment of the temporal direction of the associations found in the study [ 43 ].

Another issue that usually affect HIV studies using self-report data, including this analysis, is response bias [ 44 ]. This was apparent for age at first sexual intercourse, which necessitated the use of imputed data. This also implies that sexual behavior (e.g., condom use, etc.) and other health data collected from the respondents should be interpreted cautiously due to the possibility of Hawthorne effect [ 45 ]. Ultimately, this implies that conclusions drawn from this analysis is only as good as the quality of data provided by the respondents.

Most importantly, there have been developments in HIV testing in the Philippines since the data was collected on 2013. On 2016, the country has piloted rapid diagnostic screening tests among high-burden cities in the country to increase uptake of HIV testing. These rapid diagnostic tests have the advantage of being cheaper and having a faster turn-around time as compared to current Western blot-based confirmatory tests [ 3 , 46 , 47 ]. However, despite the rollout of these initiatives, HIV testing remains very low and falls short of the 90-90-90 target set by the DOH and UNAIDS [ 3 ]. On 2019, the country has started the implementation of the new Philippine HIV and AIDS Policy Act. Among the provisions of this new law is allowing persons aged 15–18 to undergo HIV testing without parental consent and allowing pregnant and other adolescents younger than 15 years old and engaging in high-risk behavior to undergo testing without parental consent [ 48 ]. Owing to its recent implementation, however, we are yet to measure how this new law affects uptake and utilization of HIV testing, especially among Filipino women.

Despite these weaknesses and the policy changes since the data was collected, these findings should still be considered in formulating public health interventions to promote HIV testing, considering the dearth of evidence exploring this phenomenon and the urgency of the HIV situation in the Philippines. Further research should be undertaken to elucidate the relationships of some exposures with HIV testing to improve on the weaknesses of this study as well as assess the effect of new policy developments on uptake and utilization of HIV testing among Filipino women.

The low proportion of Filipino women who have ever tested for HIV is a call to strengthen efforts to promote HIV testing. Information on its determinants can help in the formulation and implementation of interventions and which segments of the population should be targeted by these interventions. Information, education, and communication campaigns to promote HIV testing and to dispel myths surrounding it should be disseminated via television or Internet. Such campaigns should target those who have lower socio-economic status, those who have low educational attainments, and those who live in urban areas. Further research to identify determinants of HIV testing, especially among populations that were not studied yet, should be done to identify segments of the population that should be reached by interventions to promote HIV testing. Further research to assess the impact of recent policies on HIV testing should likewise be conducted. Studies and implementation research focusing on availability, accessibility, and acceptability of HIV testing, including novel and alternative approaches, such as self-testing [ 46 , 49 ] and use of technology [ 50 ] should likewise be conducted. Only through the promotion of HIV testing, and its subsequent uptake by the population, will the DOH and UNAIDS reach their targets for the Philippines.

Supporting information

S1 appendix. definition of variables and coding manual..

https://doi.org/10.1371/journal.pone.0232620.s001

Acknowledgments

We thank the DHS Program for lending us the 2013 Philippine National Demographic and Health Survey dataset. We are also grateful for the comments of Ms. Arianna Maever L. Amit and anonymous reviewer/s from the London School of Hygiene and Tropical Medicine for improving this manuscript.

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HIV/AIDS risk in the Philippines : focus on adolescents and young adults

This paper focuses on HIV/AIDS risk in the Philippines, especially adolescents and young adults.

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Published: 24 November 2021

A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data

Shobhit Srivastava ORCID: orcid.org/0000-0002-7138-4916 1 ,
Shekhar Chauhan ORCID: orcid.org/0000-0002-6926-7649 2 ,
Ratna Patel ORCID: orcid.org/0000-0002-5371-7369 3 &
Pradeep Kumar ORCID: orcid.org/0000-0003-4259-820X 1

Scientific Reports volume 11 , Article number: 22841 ( 2021 ) Cite this article

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Acquired Immunodeficiency Syndrome caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. This study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with the change in awareness level on HIV-related information among adolescents over the period. Data used for this study were drawn from Understanding the lives of adolescents and young adults, a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh. The present study utilized a sample of 4421 and 7587 unmarried adolescent boys and girls, respectively aged 10–19 years in wave-1 and wave-2. Descriptive analysis and t-test and proportion test were done to observe changes in certain selected variables from wave-1 (2015–2016) to wave-2 (2018–2019). Moreover, random effect regression analysis was used to estimate the association of change in HIV awareness among unmarried adolescents with household and individual factors. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2 to 39.1% between wave-1 & wave-2. With the increase in age and years of schooling, the HIV awareness increased among adolescent boys ([Coef: 0.05; p < 0.01] and [Coef: 0.04; p < 0.01]) and girls ([Coef: 0.03; p < 0.01] and [Coef: 0.04; p < 0.01]), respectively. The adolescent boys [Coef: 0.06; p < 0.05] and girls [Coef: 0.03; p < 0.05] who had any mass media exposure were more likely to have an awareness of HIV. Adolescent boys' paid work status was inversely associated with HIV awareness [Coef: − 0.01; p < 0.10]. Use of internet among adolescent boys [Coef: 0.18; p < 0.01] and girls [Coef: 0.14; p < 0.01] was positively associated with HIV awareness with reference to their counterparts. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups, as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents.

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Introduction.

Acquired Immunodeficiency Syndrome (AIDS) caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. So far, HIV has claimed almost 33 million lives; however, off lately, increasing access to HIV prevention, diagnosis, treatment, and care has enabled people living with HIV to lead a long and healthy life 1 . By the end of 2019, an estimated 38 million people were living with HIV 1 . More so, new infections fell by 39 percent, and HIV-related deaths fell by almost 51 percent between 2000 and 2019 1 . Despite all the positive news related to HIV, the success story is not the same everywhere; HIV varies between region, country, and population, where not everyone is able to access HIV testing and treatment and care 1 . HIV/AIDS holds back economic growth by destroying human capital by predominantly affecting adolescents and young adults 2 .

There are nearly 1.2 billion adolescents (10–19 years) worldwide, which constitute 18 percent of the world’s population, and in some countries, adolescents make up as much as one-fourth of the population 3 . In India, adolescents comprise more than one-fifth (21.8%) of the total population 4 . Despite a decline projection for the adolescent population in India 5 , there is a critical need to hold adolescents as adolescence is characterized as a period when peer victimization/pressure on psychosocial development is noteworthy 6 . Peer victimization/pressure is further linked to risky sexual behaviours among adolescents 7 , 8 . A higher proportion of low literacy in the Indian population leads to a low level of awareness of HIV/AIDS 9 . Furthermore, the awareness of HIV among adolescents is quite alarming 10 , 11 , 12 .

Unfortunately, there is a shortage of evidence on what predicts awareness of HIV among adolescents. Almost all the research in India is based on beliefs, attitudes, and awareness of HIV among adolescents 2 , 12 . However, few other studies worldwide have examined mass media as a strong predictor of HIV awareness among adolescents 13 . Mass media is an effective channel to increase an individuals’ knowledge about sexual health and improve understanding of facilities related to HIV prevention 14 , 15 . Various studies have outlined other factors associated with the increasing awareness of HIV among adolescents, including; age 16 , 17 , 18 , occupation 18 , education 16 , 17 , 18 , 19 , sex 16 , place of residence 16 , marital status 16 , and household wealth index 16 .

Several community-based studies have examined awareness of HIV among Indian adolescents 2 , 10 , 12 , 20 , 21 , 22 . However, studies investigating awareness of HIV among adolescents in a larger sample size remained elusive to date, courtesy of the unavailability of relevant data. Furthermore, no study in India had ever examined awareness of HIV among adolescents utilizing information on longitudinal data. To the author’s best knowledge, this is the first study in the Indian context with a large sample size that examines awareness of HIV among adolescents and combines information from a longitudinal survey. Therefore, this study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with a change in awareness level on HIV-related information among adolescents over the period.

Data and methods

Data used for this study were drawn from Understanding the lives of adolescents and young adults (UDAYA), a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh 23 . The first wave was conducted in 2015–2016, and the follow-up survey was conducted after three years in 2018–2019 23 . The survey provides the estimates for state and the sample of unmarried boys and girls aged 10–19 and married girls aged 15–19. The study adopted a systematic, multi-stage stratified sampling design to draw sample areas independently for rural and urban areas. 150 primary sampling units (PSUs)—villages in rural areas and census wards in urban areas—were selected in each state, using the 2011 census list of villages and wards as the sampling frame. In each primary sampling unit (PSU), households to be interviewed were selected by systematic sampling. More details about the study design and sampling procedure have been published elsewhere 23 . Written consent was obtained from the respondents in both waves. In wave 1 (2015–2016), 20,594 adolescents were interviewed using the structured questionnaire with a response rate of 92%.

Moreover, in wave 2 (2018–2019), the study interviewed the participants who were successfully interviewed in 2015–2016 and who consented to be re-interviewed 23 . Of the 20,594 eligible for the re-interview, the survey re-interviewed 4567 boys and 12,251 girls (married and unmarried). After excluding the respondents who gave an inconsistent response to age and education at the follow-up survey (3%), the final follow-up sample covered 4428 boys and 11,864 girls with the follow-up rate of 74% for boys and 81% for girls. The effective sample size for the present study was 4421 unmarried adolescent boys aged 10–19 years in wave-1 and wave-2. Additionally, 7587 unmarried adolescent girls aged 10–19 years were interviewed in wave-1 and wave-2 23 . The cases whose follow-up was lost were excluded from the sample to strongly balance the dataset and set it for longitudinal analysis using xtset command in STATA 15. The survey questionnaire is available at https://dataverse.harvard.edu/file.xhtml?fileId=4163718&version=2.0 & https://dataverse.harvard.edu/file.xhtml?fileId=4163720&version=2.0 .

Outcome variable

HIV awareness was the outcome variable for this study, which is dichotomous. The question was asked to the adolescents ‘Have you heard of HIV/AIDS?’ The response was recorded as yes and no.

Exposure variables

The predictors for this study were selected based on previous literature. These were age (10–19 years at wave 1, continuous variable), schooling (continuous), any mass media exposure (no and yes), paid work in the last 12 months (no and yes), internet use (no and yes), wealth index (poorest, poorer, middle, richer, and richest), religion (Hindu and Non-Hindu), caste (Scheduled Caste/Scheduled Tribe, Other Backward Class, and others), place of residence (urban and rural), and states (Uttar Pradesh and Bihar).

Exposure to mass media (how often they read newspapers, listened to the radio, and watched television; responses on the frequencies were: almost every day, at least once a week, at least once a month, rarely or not at all; adolescents were considered to have any exposure to mass media if they had exposure to any of these sources and as having no exposure if they responded with ‘not at all’ for all three sources of media) 24 . Household wealth index based on ownership of selected durable goods and amenities with possible scores ranging from 0 to 57; households were then divided into quintiles, with the first quintile representing households of the poorest wealth status and the fifth quintile representing households with the wealthiest status 25 .

Statistical analysis

Descriptive analysis was done to observe the characteristics of unmarried adolescent boys and girls at wave-1 (2015–2016). In addition, the changes in certain selected variables were observed from wave-1 (2015–2016) to wave-2 (2018–2019), and the significance was tested using t-test and proportion test 26 , 27 . Moreover, random effect regression analysis 28 , 29 was used to estimate the association of change in HIV awareness among unmarried adolescents with household factors and individual factors. The random effect model has a specific benefit for the present paper's analysis: its ability to estimate the effect of any variable that does not vary within clusters, which holds for household variables, e.g., wealth status, which is assumed to be constant for wave-1 and wave-2 30 .

Table 1 represents the socio-economic profile of adolescent boys and girls. The estimates are from the baseline dataset, and it was assumed that none of the household characteristics changed over time among adolescent boys and girls.

Figure 1 represents the change in HIV awareness among adolescent boys and girls. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2% in wave-1 to 39.1% in wave-2.

The percenate of HIV awareness among adolescent boys and girls, wave-1 (2015–2016) and wave-2 (2018–2019).

Table 2 represents the summary statistics for explanatory variables used in the analysis of UDAYA wave-1 and wave-2. The exposure to mass media is almost universal for adolescent boys, while for adolescent girls, it increases to 93% in wave-2 from 89.8% in wave-1. About 35.3% of adolescent boys were engaged in paid work during wave-1, whereas in wave-II, the share dropped to 33.5%, while in the case of adolescent girls, the estimates are almost unchanged. In wave-1, about 27.8% of adolescent boys were using the internet, while in wave-2, there is a steep increase of nearly 46.2%. Similarly, in adolescent girls, the use of the internet increased from 7.6% in wave-1 to 39.3% in wave-2.

Table 3 represents the estimates from random effects for awareness of HIV among adolescent boys and girls. It was found that with the increases in age and years of schooling the HIV awareness increased among adolescent boys ([Coef: 0.05; p < 0.01] and [Coef: 0.04; p < 0.01]) and girls ([Coef: 0.03; p < 0.01] and [Coef: 0.04; p < 0.01]), respectively. The adolescent boys [Coef: 0.06; p < 0.05] and girls [Coef: 0.03; p < 0.05] who had any mass media exposure were more likely to have an awareness of HIV in comparison to those who had no exposure to mass media. Adolescent boys' paid work status was inversely associated with HIV awareness about adolescent boys who did not do paid work [Coef: − 0.01; p < 0.10]. Use of the internet among adolescent boys [Coef: 0.18; p < 0.01] and girls [Coef: 0.14; p < 0.01] was positively associated with HIV awareness in reference to their counterparts.

The awareness regarding HIV increases with the increase in household wealth index among both adolescent boys and girls. The adolescent girls from the non-Hindu household had a lower likelihood to be aware of HIV in reference to adolescent girls from Hindu households [Coef: − 0.09; p < 0.01]. Adolescent girls from non-SC/ST households had a higher likelihood of being aware of HIV in reference to adolescent girls from other caste households [Coef: 0.04; p < 0.01]. Adolescent boys [Coef: − 0.03; p < 0.01] and girls [Coef: − 0.09; p < 0.01] from a rural place of residence had a lower likelihood to be aware about HIV in reference to those from the urban place of residence. Adolescent boys [Coef: 0.04; p < 0.01] and girls [Coef: 0.02; p < 0.01] from Bihar had a higher likelihood to be aware about HIV in reference to those from Uttar Pradesh.

This is the first study of its kind to address awareness of HIV among adolescents utilizing longitudinal data in two indian states. Our study demonstrated that the awareness of HIV has increased over the period; however, it was more prominent among adolescent boys than in adolescent girls. Overall, the knowledge on HIV was relatively low, even during wave-II. Almost three-fifths (59.9%) of the boys and two-fifths (39.1%) of the girls were aware of HIV. The prevalence of awareness on HIV among adolescents in this study was lower than almost all of the community-based studies conducted in India 10 , 11 , 22 . A study conducted in slums in Delhi has found almost similar prevalence (40% compared to 39.1% during wave-II in this study) of awareness of HIV among adolescent girls 31 . The difference in prevalence could be attributed to the difference in methodology, study population, and study area.

The study found that the awareness of HIV among adolescent boys has increased from 38.6 percent in wave-I to 59.9 percent in wave-II; similarly, only 30.2 percent of the girls had an awareness of HIV during wave-I, which had increased to 39.1 percent. Several previous studies corroborated the finding and noticed a higher prevalence of awareness on HIV among adolescent boys than in adolescent girls 16 , 32 , 33 , 34 . However, a study conducted in a different setting noticed a higher awareness among girls than in boys 35 . Also, a study in the Indian context failed to notice any statistical differences in HIV knowledge between boys and girls 18 . Gender seems to be one of the significant determinants of comprehensive knowledge of HIV among adolescents. There is a wide gap in educational attainment among male and female adolescents, which could be attributed to lower awareness of HIV among girls in this study. Higher peer victimization among adolescent boys could be another reason for higher awareness of HIV among them 36 . Also, cultural double standards placed on males and females that encourage males to discuss HIV/AIDS and related sexual matters more openly and discourage or even restrict females from discussing sexual-related issues could be another pertinent factor of higher awareness among male adolescents 33 . Behavioural interventions among girls could be an effective way to improving knowledge HIV related information, as seen in previous study 37 . Furthermore, strengthening school-community accountability for girls' education would augment school retention among girls and deliver HIV awareness to girls 38 .

Similar to other studies 2 , 10 , 17 , 18 , 39 , 40 , 41 , age was another significant determinant observed in this study. Increasing age could be attributed to higher education which could explain better awareness with increasing age. As in other studies 18 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , education was noted as a significant driver of awareness of HIV among adolescents in this study. Higher education might be associated with increased probability of mass media and internet exposure leading to higher awareness of HIV among adolescents. A study noted that school is one of the important factors in raising the awareness of HIV among adolescents, which could be linked to higher awareness among those with higher education 47 , 48 . Also, schooling provides adolescents an opportunity to improve their social capital, leading to increased awareness of HIV.

Following previous studies 18 , 40 , 46 , the current study also outlines a higher awareness among urban adolescents than their rural counterparts. One plausible reason for lower awareness among adolescents in rural areas could be limited access to HIV prevention information 16 . Moreover, rural–urban differences in awareness of HIV could also be due to differences in schooling, exposure to mass media, and wealth 44 , 45 . The household's wealth status was also noted as a significant predictor of awareness of HIV among adolescents. Corroborating with previous findings 16 , 33 , 42 , 49 , this study reported a higher awareness among adolescents from richer households than their counterparts from poor households. This could be because wealthier families can afford mass-media items like televisions and radios for their children, which, in turn, improves awareness of HIV among adolescents 33 .

Exposure to mass media and internet access were also significant predictors of higher awareness of HIV among adolescents. This finding agrees with several previous research, and almost all the research found a positive relationship between mass-media exposure and awareness of HIV among adolescents 10 . Mass media addresses such topics more openly and in a way that could attract adolescents’ attention is the plausible reason for higher awareness of HIV among those having access to mass media and the internet 33 . Improving mass media and internet usage, specifically among rural and uneducated masses, would bring required changes. Integrating sexual education into school curricula would be an important means of imparting awareness on HIV among adolescents; however, this is debatable as to which standard to include the required sexual education in the Indian schooling system. Glick (2009) thinks that the syllabus on sexual education might be included during secondary schooling 44 . Another study in the Indian context confirms the need for sex education for adolescents 50 , 51 .

Limitations and strengths of the study

The study has several limitations. At first, the awareness of HIV was measured with one question only. Given that no study has examined awareness of HIV among adolescents using longitudinal data, this limitation is not a concern. Second, the study findings cannot be generalized to the whole Indian population as the study was conducted in only two states of India. However, the two states selected in this study (Uttar Pradesh and Bihar) constitute almost one-fourth of India’s total population. Thirdly, the estimates were provided separately for boys and girls and could not be presented combined. However, the data is designed to provide estimates separately for girls and boys. The data had information on unmarried boys and girls and married girls; however, data did not collect information on married boys. Fourthly, the study estimates might have been affected by the recall bias. Since HIV is a sensitive topic, the possibility of respondents modifying their responses could not be ruled out. Hawthorne effect, respondents, modifying aspect of their behaviour in response, has a role to play in HIV related study 52 . Despite several limitations, the study has specific strengths too. This is the first study examining awareness of HIV among adolescent boys and girls utilizing longitudinal data. The study was conducted with a large sample size as several previous studies were conducted in a community setting with a minimal sample size 10 , 12 , 18 , 20 , 53 .

The study noted a higher awareness among adolescent boys than in adolescent girls. Specific predictors of high awareness were also noted in the study, including; higher age, higher education, exposure to mass media, internet use, household wealth, and urban residence. Based on the study findings, this study has specific suggestions to improve awareness of HIV among adolescents. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents. Investment in education will help, but it would be a long-term solution; therefore, public information campaigns could be more useful in the short term.

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This paper was written using data collected as part of Population Council’s UDAYA study, which is funded by the Bill and Melinda Gates Foundation and the David and Lucile Packard Foundation. No additional funds were received for the preparation of the paper.

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Shobhit Srivastava & Pradeep Kumar

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Srivastava, S., Chauhan, S., Patel, R. et al. A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data. Sci Rep 11 , 22841 (2021). https://doi.org/10.1038/s41598-021-02090-9

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

By Emily Mrakovcic

Illustration by Ella Olea

Introduction

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

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

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

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

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

HIV Infection Incidence Among MSM

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

Drivers and Experiences of Stigma and Discrimination

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

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

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

The HIV Health Care System

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

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

The Intersection of Health Care and Stigma

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

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

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

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

Discussion

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

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

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

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

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

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22 The Philippines

Published: December 2007
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This chapter reviews the Philippines's response to its HIV epidemic. Based on the AIDS Registry numbers, the Philippines remains a country with low HIV prevalence with a seroprevalence rate of 0.01 percent concentrated among vulnerable populations. This can be attributed to early recognition by the government, complemented by strong community interventions by non-government organizations (NGOs) and the strategic infusion of external resources from partners and donors. Collaboration among stakeholders led to sound policy formulation and comprehensive responses to HIV. Thus, although the current health system is insufficient to meet the needs of the country as it continues to undergo reforms, it has, nevertheless, been able to cope with the challenges of managing a relatively small number of affected individuals in partnership with local NGOs and external organizations.

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Open access
Published: 16 December 2022

Association of anticipated HIV testing stigma and provider mistrust on preference for HIV self-testing among cisgender men who have sex with men in the Philippines

Olivia T. Sison 1 , 2 , 3 , 4 ,
Emmanuel S. Baja 3 , 4 ,
Amiel Nazer C. Bermudez 1 , 2 , 5 ,
Ma. Irene N. Quilantang 2 , 6 , 7 ,
Godofreda V. Dalmacion 4 ,
Ernest Genesis Guevara 3 ,
Rhoda Myra Garces-Bacsal 8 ,
Charlotte Hemingway 9 ,
Miriam Taegtmeyer 9 , 10 ,
Don Operario 2 , 11 &
Katie B. Biello 1 , 6

BMC Public Health volume 22 , Article number: 2362 ( 2022 ) Cite this article

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New HIV infections in the Philippines are increasing at an alarming rate. However, over three quarters of men who have sex with men (MSM) have never been tested for HIV. HIV self-testing (HIVST) may increase overall testing rates by removing barriers, particularly fear of stigmatization and mistrust of providers. This study aimed to determine if these factors are associated with preference for HIVST among Filipino cisgender MSM (cis-MSM), and whether there is an interaction between anticipated HIV testing stigma and provider mistrust on preference for HIVST.

We conducted secondary analysis of a one-time survey of 803 cis-MSM who were recruited using purposive sampling from online MSM dating sites and MSM-themed bar locations in Metro Manila, Philippines. Summary statistics were computed to describe participant characteristics. Multivariable modified Poisson regression analyses were conducted to determine if anticipated HIV testing stigma and provider mistrust were associated with preference for HIVST among cis-MSM. Other variables such as age, education, monthly income, relationship status, HIV serostatus, and knowing where to get HIV testing were the minimal sufficient adjustment set in the analyses.

Average age of participants was 28.6 years (SD = 8.0); most had received college degrees (73%) and were employed (80%). Most respondents (81%) preferred facility-based testing, while 19% preferred HIVST. A high percentage of participants reported anticipated HIV testing stigma (66%) and provider mistrust (44%). Anticipated HIV testing stigma (aPR = 1.51; 95% CI = 1.01–2.25, p = 0.046) and provider mistrust (aPR = 1.49; 95% CI = 1.07–2.09, p = 0.020) were independently associated with a preference for HIVST. There was a positive, additive interaction between provider mistrust and anticipated HIV testing stigma on preference for HIVST (RERI = 1.13, 95% CI: 0.20–2.06; p = 0.017), indicating that the association between anticipated HIV testing stigma and preference for HIVST is greater among those with provider mistrust compared to those without provider mistrust.

Conclusions

HIVST should be offered as a supplement to traditional facility-based HIV testing services in the Philippines to expand testing and reach individuals who may not undergo testing due to anticipated HIV testing stigma and provider mistrust.

Peer Review reports

The rate of increase in new HIV infections in the Philippines is alarming [ 1 ]. On average, 42 new HIV cases per day were diagnosed in 2022 compared to 25 cases per day in 2016 and nine cases per day in 2012 [ 2 , 3 , 4 ]. Eighty-five percent of all diagnosed HIV cases in the Philippines from 2017 to 2022 were among men who have sex with men (MSM), the majority of whom were adolescents (30%) and young adults (50%) [ 3 ].

The HIV prevention continuum highlights the importance of HIV testing as an essential first step in both prevention and treatment cascades [ 5 ]. However, studies in Europe, the United States (US), South Africa, and the Philippines reported that low HIV testing uptake is associated with: sociodemographic factors such as younger age, lower education level, and higher socioeconomic status; lack of accessibility to services; lack of awareness of HIV testing and counseling; number of sexual partners; health care provider factors (e.g. onward referral due to avoidance of the issue of HIV testing); unfriendly testing environments; and psychosocial factors such as fear of rejection and disclosure, and HIV-related stigma and discrimination [ 6 , 7 , 8 , 9 , 10 , 11 ].

Voluntary facility-based testing is the primary model of HIV testing in the Philippines [ 12 , 13 , 14 ]. The most common facilities providing HIV testing services in the Philippines include hospitals, health clinics, or community-based organizations [ 12 , 13 , 14 ]. According to the Philippine Department of Health (DOH) Integrated HIV Behavioral and Serologic Surveillance data, HIV testing uptake among key populations (e.g., sex workers, MSM, people who inject drugs, transgender people) in the Philippines is low. Only 22 to 28% of MSM in the Philippines have received HIV testing between 2015 to 2019 [ 15 , 16 ]. During the first year of the COVID-19 pandemic, HIV testing in the Philippines decreased by 61% due to community restrictions that disrupted access to facility-based HIV testing services [ 14 , 17 ].

To achieve the United Nations 90–90-90 global HIV targets, with the goal of diagnosing 90% of all people living with HIV (PLHIV), providing antiretroviral therapy (ART) to 90% of those diagnosed with HIV, and achieving viral suppression for 90% of those receiving ART by 2020, the World Health Organization (WHO) launched a set of consolidated guidelines in 2016 for HIV testing services [ 5 ]. The guidelines emphasize the promise of HIV self-testing (HIVST) as an additional approach to increase HIV testing coverage, especially among MSM and other key populations [ 18 ]. Given the significant progress in addressing HIV globally, the United Nations updated the global HIV targets in 2020 and increased them to 95–95-95 [ 19 ]. This reflects the intention to diagnose 95% of all PLHIV by 2025. In response, the Philippine DOH issued an Administrative Order (AO No. 2022–0035) in August 2022 to include HIVST as one of the HIV testing options available at the primary care level in the country [ 20 ].

Previous studies in Australia, the US, Africa, and Hong Kong have shown that HIVST was generally acceptable among MSM, and that it increased HIV testing coverage because of its convenience while ensuring confidentiality and privacy [ 21 , 22 ]. Convenience, privacy, and confidentiality are motivating factors for HIVST in the Philippines [ 23 ]. A qualitative study in 2017 of key informants and stakeholders from the MSM and transgender women (TGW) communities in the Philippines found HIVST was acceptable as an additional approach to HIV testing services [ 12 ]. Due to limited access to facility-based testing services during the COVID-19 pandemic, demonstration studies were conducted in Metro Manila and Western Visayas in the Philippines and showed that HIVST was acceptable and feasible among MSM and TGW, and reactivity rate was 8–10% [ 23 , 24 , 25 ]. In these demonstration studies, HIVST was made available using courier delivery methods and via in-clinic appointments.

The acceptability and feasibility from these demonstration studies showed the promise of HIVST as a strategy to increase HIV testing coverage among key populations in the Philippines. However, factors contributing to HIVST uptake in the country must be further studied as there still remain some concerns regarding accessing the service, particularly the lack of privacy and maintenance of confidentiality during delivery of HIVST kits [ 23 ]. Studies on preference for HIVST, including identifying motivating factors as well as barriers to use, can guide HIVST roll out in the country.

Studies in the US found that experiencing stigma and medical-related mistrust have each been associated with lower engagement in care or underutilization of health services [ 11 , 26 , 27 , 28 , 29 , 30 ]. In particular, anticipated stigma was found to be a significant predictor of HIV testing behavior [ 31 , 32 ]. Anticipated stigma refers to an individual’s expectation to experience prejudice and discrimination from others in the future [ 33 ]. In a scoping review of health-related stigma outcomes in low- and middle-income countries, anticipated stigma was associated with decreased voluntary HIV testing [ 34 ]. Our study explored two specific areas of medical-related mistrust: mistrust in health care providers and mistrust in the health care facility [ 35 ]. Higher levels of provider mistrust among people living with HIV have previously been associated with suboptimal engagement with health care [ 11 ]. Provider mistrust and stigma are important determinants for poorer health outcomes because these potentially modifiable factors might influence health care utilization and thus affect the overall health among the high-risk groups. The additive effects of experiencing both anticipated stigma and provider mistrust have received limited research attention and deserve attention. A systematic review of research conducted in multiple global contexts found that HIVST is particularly promising among MSM who often encounter structural barriers, such as stigma and discrimination, that deter them from accessing HIV-related services [ 36 , 37 ].

To date, there is a paucity of data in the Philippines on preferences for HIVST among MSM and correlates of HIVST preferences in this population. This study aimed to (i) determine the percentage of cis-MSM in the Philippines who prefer HIVST rather than the traditional facility-based HIV testing services, (ii) determine if anticipated HIV testing stigma and provider mistrust were associated with preference for HIVST among Filipino cis-MSM, and (iii) examine whether there is an interaction between anticipated HIV testing stigma and provider mistrust on preference for HIVST.

Study design and setting

This study analyzed data from the HIV Gaming, Engaging, and Testing (HIV GET) Project, which had an overarching aim to develop and evaluate a mobile game application to address identified barriers to HIV services [ 38 ]. Targeted messaging was used to recruit HIV GET study participants via posting of study flyers and in-person outreach at venues where MSM frequent, and advertisements on MSM dating sites (e.g., Grindr, Planet Romeo, and GROWLr) and MSM-themed bar locations in Quezon City, Philippines. Participants were eligible if they were at least 18 years old, assigned male sex at birth, self-identified as MSM, and were able to give informed consent. Given the overarching project aims, HIV status was not a criterion for enrollment. Using purposive sampling, a total of 899 participants completed the survey between October and November 2016. We excluded in the analytic sample participants who did not identify as cis-MSM and those who self-reported to be HIV positive. A total of 803 cis-MSM was included in this secondary analysis. More than a quarter of these participants resided outside Metro Manila.

Screening questions were used to identify eligible participants, and those who were eligible were redirected to the main survey questionnaire page. Participants recruited from bar locations completed a survey administered via mobile tablet. Participants recruited via social media platforms responded to study informational messages posted on targeted websites. Those who clicked the advertisement on these sites were redirected to the informed consent page for the online survey. Survey questions were in English and Tagalog (local language). The survey questions were developed based on findings from an unpublished qualitative study among MSM, TGW, and HIV service providers [ 38 ]. Survey participants were not compensated in this study.

Dependent variable

Preferred HIV testing method. Participants selected their preferred HIV testing method from the following options: (1) hospital-based testing, (2) clinic-based testing (social hygiene clinics) , (3) home-based testing with a health worker, (4) community-based testing with a health worker, and (5) self-testing. This was coded as a binary variable (HIV self-testing vs. any other preferred option).

Independent variables

We assessed anticipated HIV testing stigma and provider mistrust as exposures of interest . As noted, items for both constructs were based on preliminary findings from a qualitative study of HIV testing preferences among key populations in the Philippines [ 38 ]. Anticipated HIV testing stigma was measured based on respondents’ level of agreement with the following statements: (1) I feel like I would be stigmatized going to an HIV/AIDS testing facility, (2) I worry about being recognized at the HIV/AIDS testing facility, (3) I feel like the staff would disrespect me (Cronbach α = 0.80) . Provider mistrust was assessed based on respondents’ level of agreement with the following statements: (1) I don’t think there will be anyone in the HIV/AIDS testing facility that I can trust to talk to , (2) I don’t trust the counselors at the HIV/AIDS testing facility , (3) I don’t trust the people that take your blood at the HIV/AIDS testing facility , (4) I don’t trust the results you get at the HIV/AIDS testing facility (Cronbach α = 0.89). The level of agreement for the statements was measured using a 7-point Likert scale (strongly disagree to strongly agree), and responses were dichotomized. If respondents agreed or strongly agreed to at least one of the statements indicative of anticipated HIV testing stigma and provider mistrust, they were coded as experiencing anticipated HIV testing stigma and provider mistrust, respectively.

Sociodemographic and other participant characteristics

The respondent’s age in years was categorized as 18–24, 25–34, ≥35. Educational attainment was coded as a binary variable (graduated from college or higher vs. some college and below). Monthly income was categorized based on a defined poverty threshold as 10,000 pesos and below (≤USD 207) or more than 10,000 pesos (>USD 207) [ 39 ]. Participants’ relationship status was classified as follows: single, not looking for a relationship; single, looking only for serious relationship; single, looking only for casual relationships; in a relationship, exclusive; and in a relationship, open. Participants’ recent HIV testing experience was probed (never been tested, past 12 months, more than a year ago), and their self- reported awareness of HIV status was categorized as HIV negative, HIV positive, unsure, did not want to answer. Those who self-reported to be HIV positive were excluded in the analytic sample. They were also asked if they knew where to get HIV testing (yes vs. no). Survey respondents were asked about their sexual orientation with the following response options: (1) heterosexual, (2) gay/homosexual, (3) bisexual, (4) discreet (do not openly disclose sexual activities), (5) not in any category.

Data analysis

Frequencies and percentages were calculated for categorical variables. Means, standard deviations, and ranges were calculated for continuous variables. To determine the internal consistency of our scale variables, we computed for Cronbach’s alpha. Separate bivariable modified Poisson regressions were performed to estimate the prevalence ratios for the association between preference for HIVST and the following covariates: age, relationship status, level of education, employment status, monthly income, knowing where to get HIV testing, recent HIV test, awareness of HIV status, anticipated HIV testing stigma, and provider mistrust. Modified Poisson regression was used to estimate prevalence ratios rather than odds ratios because the dependent variable was not rare [ 40 , 41 ]. Directed acyclic graphs (DAG) were constructed to determine the minimum set of covariates to adjust for in the analysis of the association between anticipated HIV testing stigma and preference for HIVST, and provider mistrust and preference for HIVST using Causal Fusion (See Additional file 1 ) [ 42 ]. All variables included in the DAG, as well as their interrelationships were determined a priori through expert knowledge and literature review. Using the DAGs constructed for this study, the association of the exposure variables with preference for HIVST was considered unbiased given a set of covariates S if, after conditioning on S , the open paths between the exposure variables and preference for HIVST were exactly the directed paths from the exposure variables to preference for HIVST. A variable was considered a component of S if conditioning on it blocks biasing backdoor paths [ 43 ]. For our study, the minimal sufficient adjustment set includes age [ 8 , 31 , 44 , 45 , 46 ], level of education [ 8 , 45 , 46 , 47 ], monthly income [ 10 , 46 ], relationship status [ 8 , 48 ], awareness of HIV status [ 6 , 49 ], and knowing where to get HIV testing [ 7 , 8 , 9 , 10 ]. Multivariable modified Poisson regression analyses were performed to estimate prevalence ratios for the association of exposure variables and preference for HIVST, adjusting for the covariates described previously. Separate generalized linear models with Poisson distribution and log link were constructed with anticipated HIV testing stigma and provider mistrust as independent variables in the two models (Models 1 and 2). A third model was constructed to explore the interaction between anticipated HIV testing stigma and provider mistrust on preference for HIVST (Model 3). The statistical interaction on the additive scale between anticipated HIV testing stigma and provider mistrust was determined by estimating the relative excess risk due to interaction (RERI) and its 95% confidence interval (CI), following the method outlined by VanderWeele [ 50 ]. A RERI of greater than zero denotes a positive interaction on the additive scale between anticipated HIV testing stigma and provider mistrust on preference for HIVST. Positive interaction in this study would denote a stronger association between anticipated HIV testing stigma and preference for HIVST among those who have provider mistrust compared to those who do not have provider mistrust. Estimating interaction on the additive scale is considered more relevant in evaluating the public health impact, as it suggests which exposure group to target for an intervention [ 50 ]. The ratio of prevalence ratios was also reported as the measure of multiplicative interaction, where a ratio of one means no interaction and a ratio bigger than one indicates positive interaction on the multiplicative scale. Adjusted prevalence ratios (aPR) and their 95% CIs relating the independent variables and preference for HIVST are presented [ 51 ]. Data management and statistical analyses were performed using Stata version 16 [ 52 ].

Table 1 summarizes the overall sample characteristics of the participants. In brief, survey participants were between 18 and 61 years old with an average age of 28.6 years (SD = 8.0), mostly with college degrees (73%) and employed (80%). The majority of the sample identified as gay/homosexual, more than a quarter identified as bisexual, while 17% did not openly disclose their sexual orientation. More than half (57%) reported to be HIV negative and one-third were unsure of their HIV status. Almost half (45%) of the respondents had undergone HIV testing in the past 12 months. However, 37% ( N = 293) had never been tested for HIV, although 70% of all participants knew where to get HIV testing. Almost two out of ten (19%) preferred HIV self-testing over in-person, facility-based HIV testing methods.

Table 2 presents participants’ level of agreement with items assessing for anticipated HIV testing stigma and provider mistrust. Overall, 66% ( N = 519) agreed to at least one statement pertaining to anticipated HIV testing stigma, while 44% ( N = 338) reported mistrust of health care providers in the testing facilities.

Table 3 presents (i) bivariable associations between all covariates and preference for HIVST, and (ii) adjusted associations of anticipated HIV testing stigma and provider mistrust with preference for HIVST. Participants who preferred HIVST tended to be older, unsure of their HIV status, did not know where to get HIV testing, and had never been tested for HIV nor was currently engaged in routine testing. Both anticipated HIV testing stigma and provider mistrust were associated with participants’ preference for HIVST over the other HIV testing methods. In adjusted analyses, anticipated HIV testing stigma was associated with a 51% increase in the prevalence of HIVST preference (aPR = 1.51; 95% CI = 1.01–2.25, p = 0.046), and provider mistrust was associated with a 49% increase in the prevalence of HIVST preference (aPR = 1.49; 95% CI = 1.07–2.09, p = 0.020).

There was a significant positive, additive interaction between provider mistrust and anticipated HIV testing stigma on preference for HIVST (RERI = 1.13, 95% CI: 0.20–2.06; p = 0.017), indicating the association between anticipated HIV testing stigma and preference for HIVST is greater among those with provider mistrust compared to those without provider mistrust. On the multiplicative scale, there was a positive interaction trend between provider mistrust and anticipated HIV testing stigma on preference for HIVST, but this fell short of statistical significance ( p = 0.168 ). Table 4 summarizes the stratified results. After adjusting for all covariates, provider mistrust was positively and significantly associated with preference for HIVST (aPR = 1.54; 95% CI = 1.00–2.36, p = 0.050) among those with anticipated HIV testing stigma, and anticipated HIV testing stigma was also positively but non-significantly associated with preference for HIVST among respondents who reported to have provider mistrust (aPR = 3.71; 95% CI = 0.67–20.39, p = 0.132).

Our study is the first known quantitative assessment of preference for HIVST among cis-MSM in the Philippines, who comprise more than 80% of all diagnosed HIV cases in the country [ 4 ]. Over 60% of survey participants had ever been tested for HIV with 45% having been tested in the past 12 months. This percentage was higher than the reported estimate that only 22% of Filipino MSM had ever been tested for HIV [ 15 ]. It is possible that because survey respondents were recruited in social venues where HIV prevention and testing messages exist, members of this study sample were more likely to have been tested for HIV.

Almost one fifth of the survey participants (155/803) preferred HIVST. This subgroup tended to be older, unsure of their HIV status, did not know where to get HIV testing, and had never been tested for HIV nor was currently engaged in routine testing. Compared to previous studies in other parts of the world which found that HIVST was highly acceptable to target users including MSM [ 12 , 44 , 53 , 54 , 55 , 56 ], the percentage of MSM in our sample who preferred HIVST was lower than expected. One possible reason for the lower preference for HIVST in this group is the moderate level of awareness about HIVST in the study sample. At the time of this report, only 56% of MSM in the Philippines had heard about HIVST [ 57 ]. Moreover, at the time of data collection for this study, HIVST was also not yet included in the national HIV testing policies and guidelines in the Philippines and WHO-approved self-test kits are unavailable. These may have contributed to lower than expected levels of preference for HIVST observed here.

More than half of the participants in the sample preferred facility-based HIV testing. Similar studies in the United Kingdom (UK) and Ireland conducted after the timing of our survey also found MSM still prefer facility-based HIV testing [ 58 , 59 ]. Some possible reasons for choosing facility-based HIV testing include the opportunity for engagement with a live, in-person counselor and access to ancillary services (e.g., referrals to mental health or social service programs; linkage to HIV care for those testing HIV positive) provided in the testing facility [ 21 ]. Preference for HIVST in this population is likely to increase as awareness of and trust in this testing modality grow in the Philippines. This was evident during the COVID-19 pandemic when community quarantines were enforced and access to in-clinic testing were limited [ 17 , 25 ]. HIV-focused community-based organizations (CBO) reported that delivery of HIV-related services, including HIVST, and conduct of HIVST with assistance by an HIV counselor via online platforms ensured that HIV testing services were continuously accessible to key populations and even first time users during the pandemic [ 17 , 25 , 60 ]. Given the confidentiality, privacy, and independence that HIVST provides, as well as the convenience of accessing it, if accessed via courier services facilitated by CBOs or HIV treatment facilities, HIVST proves to be a promising HIV-related service in the Philippines [ 17 , 23 , 25 , 60 ]. Thus, HIVST can be considered as supplementary to facility-based testing rather than needing to replace traditional HIV testing services [ 61 ]. Traditional HIV testing and HIVST may co-exist in the HIV testing services framework [ 62 ]. In fact, a meta-analysis conducted in 2017 showed that providing HIVST in addition to traditional testing modality significantly increased HIV testing uptake [ 22 , 63 ].

Provider mistrust and stigma are salient barriers to healthcare utilization and affect the overall health among vulnerable high-risk groups such as MSM [ 11 , 26 , 27 , 28 , 30 , 31 , 32 , 64 ]. A global systematic review including 18 studies reported that preferences for HIVST was due to increased convenience and confidentiality, especially among stigmatized populations and decreased test-associated stigma [ 65 ]. A significant percentage of our study participants reported anticipated HIV testing stigma and mistrust of health care providers in the testing facilities. Both anticipated HIV testing stigma and provider mistrust were associated with preference for HIVST. These findings are consistent with previous studies reporting that stigma and physician mistrust were associated with HIV testing behavior and utilization of health services among MSM [ 11 , 27 , 28 , 30 , 31 , 32 ]. Our findings suggest an opportunity to increase HIV testing in the Philippines by offering HIVST as an option for individuals concerned about stigma and provider mistrust. Moreover, efforts to rebuild trust in health care providers and address sources of stigma among Filipino MSM and other key populations are also needed to improve HIV testing uptake and engage members of these groups in necessary healthcare services. Indeed, as an early effort to address this concern, a “sundown clinic” (i.e., one that operates beyond traditional “daylight” working hours) was established in Quezon City, Philippines in 2012 and was considered non-stigmatizing and a safe space for MSM and transgender people for receiving HIV testing and counseling services [ 66 ]. However, future efforts to scale-up this initiative to different areas in the country are much needed.

There are several limitations of the study. First, participants were recruited via MSM social venues and mobile dating apps, and most of the participants were between 18 to 34 years old and were highly educated and employed. Thus, this study sample population may not reflect the Philippines’ general MSM population. Second, sexual behaviors were not measured, and HIV status was assessed via self-report. Therefore, the risk for HIV infection/transmission in our sample population is unclear. Third, social desirability may have led to overreporting of recent HIV testing and underreporting of HIV serostatus. Fourth, residual confounding may have been introduced due to possible unmeasured confounders, such as health service delivery and health provider factors that were not assessed in our study. We recommend future research studies investigate these multilevel determinants, and possibly examine contextual effects. Future research studies should look into other forms of stigma, the differences in experiences in health care stigma, and the difference in attitudes towards HIVST based on gender identity and sexuality. Fifth, exposure misclassification may have been introduced due to the limitations inherent to the secondary analysis of an existing dataset; however, we assume that these exposure misclassifications are likely to be non-differential with respect to the outcome, given that exposure definitions were developed post-data collection stage. A total of 223 (28%) of the observations were excluded in the adjusted analysis due to missing information mostly on income and some other covariates. There was no evidence of an association between missingness and our primary outcome, and that the complete case analysis estimates of exposure associations can be asymptotically unbiased [ 67 ]. Finally, due to the cross-sectional nature of the study, findings are descriptive and preclude temporal or causal inferences.

This study conducted among cis-MSM in the Philippines suggests that one out of five cis-MSM preferred HIVST over the traditional HIV testing strategies. An upsurge in preference for HIVST among cis-MSM in the Philippines may increase with expanded campaigns to raise awareness, understanding, and access to HIVST methods in the future. Moreover, Philippines national HIVST guidelines and access to WHO-approved HIVST materials are likely to increase levels of awareness, acceptability, and uptake of HIVST. Therefore, our findings reported here offer a baseline description of preference for HIVST prior to the implementation of structural programs to promote HIVST. In addition, anticipated HIV testing stigma and mistrust of health care providers in the testing facilities were reported, and both factors were associated with a higher prevalence of HIVST preference. HIVST represents a compelling complementary option to traditional HIV testing services in the Philippines, which can expand testing among cis-MSM who do not undergo testing due to anticipated HIV testing stigma and provider mistrust and provide differentiated HIV testing service delivery options to specific subgroups among key populations.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available in the Harvard Dataverse repository, https://doi.org/10.7910/DVN/PFUMZM .

Abbreviations

Acquired immunodeficiency syndrome

Confidence Interval

Directed acyclic graph

Department of Health

Human immunodeficiency virus

HIV Gaming, Engaging, and Testing

HIV self-testing

Men who have sex with men

People Living with HIV

Prevalence Ratio

Relative Excess Risk due to Interaction

Standard Deviation

Transgender women

World Health Organization

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Acknowledgements

We would like to acknowledge the participants of this study, the HIV Gaming, Engaging, and Testing (HIV GET) project research team from the University of the Philippines-Manila, Klinika Bernardo, Love Yourself Anglo, and the Liverpool School of Tropical Medicine, and the Philippine-UK Newton-Agham Program of the Medical Research Council, United Kingdom and the Philippine Council for Health Research and Development, Department of Science and Technology, Philippines.

This work was supported by the National Institutes of Health-Fogarty International Centre under Grant D43TW010565–02. Ms. Sison was a Graduate Fellow under the grant of Brown University and University of the Philippines Training Program for the Prevention of HIV in Vulnerable Populations. Dr. Baja’s effort was supported by the Newton Agham Grant through the UK Medical Research Council and Philippines Council for Health Research and Development, Department of Science and Technology (FP160001). The views and opinions expressed in this article are solely those of the authors and do not necessarily represent the official views of the sponsor. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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OS, EB, AB, MIQ, GD, EG, CH, MT, DO and KB were involved in the conceptualization of this paper. EB, GD, EG, RB, CH, and MT collected the data. OS, DO, and KB designed the analysis for this paper. OS conducted the data analysis and wrote the paper. OS, EB, MIQ, and DO revised the manuscript. All authors read and approved the final manuscript.

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OS: Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA; The Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island, USA; Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Philippines.

EB: Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Philippines.

AB: Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA; The Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island, USA; Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines Manila, Philippines.

MIQ: Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA; The Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island, USA; Department of Behavioral Sciences, College of Arts and Sciences, University of the Philippines Manila, Philippines.

GD: Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Philippines.

EG: Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines Manila, Philippines.

RB: Department of Special Education, College of Education, United Arab Emirates University, P.O. Box 15551, Al Ain, UAE.

CH: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Palace Liverpool, Liverpool L3 5QA, UK.

MT: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Palace Liverpool, Liverpool L3 5QA, UK; Tropical Infectious Disease Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK.

DO: The Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island, USA; Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.

KB: Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.

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Sison, O.T., Baja, E.S., Bermudez, A.N.C. et al. Association of anticipated HIV testing stigma and provider mistrust on preference for HIV self-testing among cisgender men who have sex with men in the Philippines. BMC Public Health 22 , 2362 (2022). https://doi.org/10.1186/s12889-022-14834-x

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1473 HIV in Pregnant Women in the Philippines: Revisiting Prospects for Universal Screening

Maria jasmin marinela bartolome.

1 Department of Medicine, Section of Infectious Diseases, University of the Philippines - Philippine General Hospital, Manila, Philippines

Oliver Sanchez

Marissa alejandria, angel bandola.

2 Department of Obstetrics and Gynecology, Section of Infectious Diseases, University of the Philippines - Philippine General Hospital, Manila, Philippines

Richelle Duque

Edsel maurice salvana.

3 Institute of Molecular Biology and Biotechnology, National Institutes of Health, University of the Philippines, Manila, Philippines

Session: 193. Global HIV and TB

Saturday, October 11, 2014: 12:30 PM

Background. The Philippines is one of nine countries globally with rapidly increasing rates of HIV infection. Annual reported cases have increased 34-fold in the last decade. A local prevalence study of 3,000 pregnant women in 1998 failed to find a single case of HIV. This study aims to determine whether universal HIV screening in pregnant women should be initiated in the light of the large number of newly-diagnosed cases.

Methods. Following institutional review board approval, adult pregnant patients at the Philippine General Hospital (PGH) were recruited into the study. PGH is the largest tertiary-care government hospital in the country and is a national referral center. 400 pregnant women were offered free HIV testing and 387 women qualified for the study. Demographics and risk factors for HIV were recorded and analyzed. Screening was done using ELISA/ECLIA testing (Abbott Architect HIV Ag/Ab) with Western blot for confirmation.

Results. Demographics and HIV risk factors are shown in the table. No pregnant women were found to have HIV. Two false positives occurred.

In order to better analyze risk factors for screening, we compared the demographics and risk factors of the study patients with the records of all (N = 4) pregnant HIV patients seen in our HIV clinic at PGH. Differences between HIV-positive vs HIV-negative pregnant women included more sexual partners (5 vs 2); higher rates of illicit drug use (50% vs 0.78%), sex with foreigners (50% vs 1.6%) STD rates (25% vs 3.9%), sex with illicit drug users (25% vs 3.1%), and receiving money for sex (50% vs 0.52%).

Demographics and risk factors (N=387)

Age (years)	Mean: 28.4 SD: 6.2	Range 19-46
Age of gestation (weeks)	Mean: 27.06 SD: 8.01	Range: 4 to 38
Number of partners (lifetime)	Mean: 1.92 SD: 1.61	Range: 1 to 20
History of sexually transmitted disease	Yes: 15 (3.88%)	No: 372 (96.12%)
Condom use	Yes: 65 (16.80%)	No: 322 (83.20%)

Conclusion. Universal screening for HIV in pregnant Filipino women is not supported by the findings of this study despite the tremendous increase in HIV prevalence in the Philippines. A larger sample size may be useful to strengthen this assertion. Targeted HIV screening of pregnant women, particularly female sex workers, drug users and those with multiple partners should be offered.

Disclosures. All authors: No reported disclosures.

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1473 HIV in Pregnant Women in the Philippines: Revisiting Prospects for Universal Screening

Oliver Sanchez

Richelle Duque

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