UNDER THE MICROSCOPE Dr. Raymund W. Lo Dramatic as the Covid-19 pandemic is, we should remember that its death toll is dwarfed by that of HIV/AIDS, which has so far killed 36.3 million people since it started in 1980. Yet, we seem to have forgotten about this dreaded disease. It is still very much with us, and it continues to affect millions around the world. In fact, 37.7 million people were living with HIV/AIDS at the end of 2020. In the Philippines, there are 220,000 people living with HIV/AIDS (PLWHA), according to the HIV/AIDS World Data. Reported new infections were 17,000 in 2020, most probably an underestimate due to the pivot of the health care system towards Covid-19, since there were 53,104 HIV cases reported in 2019. I can attest to that, because in my line of work as a pathologist, I encounter a lot of requests for immunodeficiency panels, where the CD4 (helper cell) count is low to almost zero, indicating a very immunocompromised state. Many of these are in young males, sometimes as young as 16, which is the age group with the largest majority of PLHIV. Judging from the markedly low CD4 counts, these are probably in the late stage of AIDs, with many prone to opportunistic infections, such as Pneumocystis pneumonia. Based on figures, over 50 percent are diagnosed in the late stage (AIDS). These cases will in all probability not be formally diagnosed as HIV/AIDS due to the stigma attached to the disease as well as the circumscription of medical insurance, which will not cover cases of diagnosed HIV/AIDS. So, patients and doctors play a hide-and-seek game to enable hospitalization of these cases. Testing is either done surreptitiously in outside labs for diagnosis or just assumed by the clinician based on symptoms and lab results, especially in men who have sex with men (MSM), which compose 96 percent of cases in the Philippines. What’s sad is that these are people in what should be their most productive years; yet, they are sidelined by the disease and even become a burden on the economy. This is the hidden pandemic now haunting the country. The Philippines has one of the fastest-growing number of cases worldwide. The main problem is that it is hidden; hence, without good data on the number of cases, there can’t be good programs for treatment, prevention, and education. It all boils down to doing more testing, especially among at-risk populations: MSM, commercial sex workers, and transgender persons. Elsewhere, HIV testing is readily available at points of contact with target populations at no cost and done anonymously. Here in the Philippines, testing is not free, and persons seeking the test have to undergo counseling and sign consent forms that sacrifice anonymity. Ironically, the current law on HIV/AIDS hampers rather than encourages testing. Such requirements actually hinder access to HIV testing, since the process is time consuming and requires face-to-face interaction with health care providers. The data speaks for itself. Only 16 percent of MSM undergo testing, while estimated prevalence in this population is five percent. This disconnect is fueling a surge in HIV infections. The country’s incidence rate went from 0.10 in 2010 to 0.20 in 2020, a 100 percent increase. Clearly, the current approach to testing is not producing a reduction in HIV transmission. We need to make HIV testing much more accessible, faster, and with anonymity. Coupled with an effective educational campaign on HIV prevention and treatment, we can reduce the rate of new infections with this approach, which gives the individual complete control over his decisions on when and where to test, and how he/she can access preventive care and treatment. For example, if one can ascertain his HIV status privately, he can exert more effort in not transmitting it to another person by using condoms, which only 40.6 percent of MSM do. Likewise, he can also access treatment hubs for effective anti-retroviral (ARV) drugs, which when taken regularly, can give an HIV-positive person a normal/near normal lifespan. However, only 44 percent of diagnosed cases are currently on ARV. Untreated cases usually die within three to five years. If we were to make it easier to get tested for free at clinics located in communities identified as being frequented by MSM, and if the test results were to be communicated by text messages, I’m sure there would be more testing among this population. This can easily be achieved by the use of dried blood spots, which is less invasive, and can be performed by a minimally trained person. These are also easier to transport with less biohazard risk. Testing can be done at a centralized facility using pooled testing, thus reducing costs. This will of course require a change in policies and a reset of the bureaucratic mindset that more regulation is better. But hope springs eternal.