CLINICAL MATTERS
When I returned to the Philippines as a Balik Scientist in 2009, little did I know I would be playing a major role in fighting HIV in our country. When I graduated from medical school at the University of the Philippines (UP) College of Medicine in 2001, I knew very little about HIV.
There weren’t very many cases. In fact, I only saw about two full blown AIDS patients in the five years of clinical rotations I spent at the Philippine General Hospital (PGH). This was a mystery to the world, and some scientists even asked the question whether Filipinos had some built-in immunity to HIV. Unfortunately, it turned out we were just very, very lucky and, by the time I returned, our luck had run out.
HIV in the Philippines is transmitted predominantly through sex. While there is some documented transmission from IV drug use and from mother to child, over 99 percent of the cases have been sexually transmitted. This can be partially attributed to our dismal condom use, which is only at 30 percent, the lowest in Asia. While HIV awareness has grown by leaps and bounds since 15 years ago, stigma is still very much around.
Stigma prevents people from testing for HIV early, when treatment is most likely to be effective. Stigma prevents people from seeking care and staying in care, leading to needless deaths among very young people.
When I first started seeing patients as a young attending physician at the HIV treatment hub at PGH in 2009, there were very few options for antiretroviral treatment. Unlike today where everyone gets treated as soon as the diagnosis is made, we only started treatment back then when the CD4 count was 200 cells/mm3 or below.
By then, the patient had full blown AIDS. Many people died as a result of opportunistic infections that occurred due to their ravaged immune system. Moreover, the antiretrovirals we had back then were not as good as the ones we have now, and had some pretty significant side effects. Nevertheless, we were able to save many lives with what we had at that time. Recognizing that there was so much that needed to be done, I started doing advocacy work to raise awareness and increase our resources for fighting HIV in our country.
One such project was the Philippine Red Party, which mounted a rock concert in cooperation with the Australian Red Party in order to purchase a much-needed CD4 counting machine for our PGH lab. CD4 counts are an essential part of HIV care and there were only a few labs that were performing it. The concerts were very successful and we were able to purchase a state-of-the-art CD4 machine.
While my first love in infectious diseases was parasitology, I knew I had to shift gears to HIV. We conducted groundbreaking research in HIV at the National Institutes of Health at UP-Manila. These studies included HIV coinfection in TB and sexually transmitted diseases; factors that determined mortality among HIV patients; and baseline studies on acquired and transmitted drug resistance. Many of these studies were utilized by the Department of Health to support changes in policies for HIV care for the better. Some were used in formulating clinical practice guidelines. The World Health Organization has cited some of our work as foundational data for subsequent research.
Our latest project, which is funded by the Department of Science and Technology through the Philippine Council for Health Research and Development, involved the development of a portable HIV drug resistance test. One out of 10 Filipinos living with HIV already has preexisting drug resistance prior to starting antiretrovirals. Undetected, this significantly increases the risk of treatment failure and death. HIV drug resistance testing typically requires a very sophisticated laboratory with expensive specialized equipment. In fact, there are currently only two laboratories in the Philippines that do HIV drug resistance testing—the Research Institute for Tropical Medicine laboratory and our own Central Laboratory at the National Institutes of Health.
We developed an accurate, quick, and portable HIV drug resistance test that can be deployed in resource-limited settings at half the cost of a conventional test. This uses a harmonica-sized portable DNA sequencing machine known as a MinION to read a portion of the HIV genome. Prior to the pandemic, one of the biggest concerns we had was that the test required an RT-PCR step prior to doing sequencing in order to turn HIV RNA into DNA and to enrich the amount of material for sequencing. We knew that there were very few RT-PCR capabilities at that time and so we were working on a technological solution to this as well. When the Covid-19 pandemic occurred, hundreds of laboratories suddenly acquired the ability to do RT-PCR. With this development, it becomes much easier to deploy this novel solution to HIV drug testing.
We worked on this project for several years and finally came up with a fairly accurate test. We performed the test on stored laboratory samples and we were able to show that it performed as well as the standard Sanger test that is conventionally used for detecting HIV drug resistance. We entered our project in the IDea Incubator contest of the Infectious Diseases Society of America Foundation, which is held at the IDWeek conference annually. IDWeek is a joint annual convention of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the Pediatric Infectious Diseases Society, and the HIV Medical Association. It is considered the premier infectious diseases conference in the world and regularly features eminent infectious diseases speakers such as Dr. Anthony Fauci.
A few months prior to the convention, I was notified that our innovation had made it to the top three and that we were going to present our work at IDWeek in Boston. This is a tremendous honor, because our innovation beat many different projects from all over the world. As I write this column, I am already in Boston preparing for the contest. Whatever the outcome, this is already a win for the Philippines because it shows that we are capable of producing world-class innovations. The test itself has the potential to transform HIV care not just in the Philippines but also for the rest of the world.