CLINICAL MATTER
As we emerge from the Covid-19 pandemic, HIV is once again rearing its ugly head, infecting young Filipinos at an unprecedented rate. In the past decade, the Philippines has had one of the fastest growing HIV epidemics in the world. Between 2010 and 2021, the number of new local HIV cases in a year has grown by more than 600 percent even as new infections worldwide have gone down by 32 percent. After a significant drop in cases diagnosed during the Covid-19 pandemic, the numbers have alarmingly rebounded and exceeded the pre-pandemic infection rate. From one case a day from 15 years ago, the infection rate in 2023 is tracking at over 50 newly diagnosed infections per day. This does not include people living with HIV (PLHIV), who have not taken a test and remain undiagnosed even as the virus slowly destroys their immune system.
Graph showing increase in HIV cases in the Philippines since 1984, including a temporary drop during the pandemic. (Source: Epidemiology Bureau of DOH)
Last month I took care of two newly diagnosed HIV patients admitted to the hospital who had very different outcomes. Some details of their cases have been changed to protect their privacy. The first patient was a young man in his late 20s who had been experiencing fever for the last few months and came in with a painful enlarged lymph node. A biopsy showed tuberculosis. This made me test for HIV, regardless of his risk factors. Since the risk of having tuberculosis when you have HIV is more than 10 times that of someone who is not infected with HIV, it is important to do an HIV test on anyone with active tuberculosis, especially young people who should have healthy immune systems. He then developed shortness of breath, which I recognized as Pneumocystis pneumonia (PCP), one of the most common killers of patients with AIDS. I immediately started steroids and antibiotics and thankfully he had a good response. Discharged from the hospital a few days later, he is now enrolled in a treatment hub for antiretroviral therapy (ART). He is very lucky since more than 50 percent of PLHIV who present with severe do not survive the episode. With hope, he continues to do well.
The second patient wasn’t so lucky. He was transferred to me from another hospital. He had been having fever and headaches for a few weeks and was diagnosed with Cryptococcus meningitis – a deadly fungus growing in the brain. Crypto meningitis usually shows up in advanced AIDS where the CD4 count is below 50 cells/mL (normal is >500 cell/ml) and carries a grave prognosis for most patients. The treatment of choice, amphotericin B, is quite toxic and can cause kidney failure. We could not start ART since this is contraindicated in acute cryptococcus meningitis. Unfortunately, a few days later he lost consciousness and became unarousable. The pressure in his brain was too much and he did not respond to further treatment. He eventually died when the family elected to withdraw care as he was already brain-dead. He was 30 years old.
What is most tragic, especially for the second case, is that these outcomes were preventable. There are proven ways to prevent HIV. For those who end up being infected, there is very good treatment that can prolong life if started early enough.
HIV in this day and age is no longer a death sentence. The advent of highly effective ART has nearly restored life expectancy to PLHIV as long as they start treatment early in the course of the disease. This means that ART works best when someone is tested as close to the time of infection as possible and accesses care quickly. Unfortunately, due to the stigma associated with HIV, many people are scared to test. It is a misconception that only people with “high-risk” behavior should be tested. Anyone who is sexually active (even with a single partner!), pregnant, has active tuberculosis, or has a history of sexually transmitted infections should get a test. The US CDC advocates that everyone should get at least one HIV test in their life, since many people who have tested positive never considered themselves to be high risk. Many times, patients come to our clinics with full blown AIDS and it is much more difficult to treat them. In some cases, it is too late to save them.
Properly taken, ART suppresses HIV viral replication to the point where PLHIV are no longer infectious. This means that PLHIV can safely have children the natural way, work as surgeons, and do other activities previously considered potentially infectious as long as they are on effective ART with a low or undetectable viral load. ART in the Philippines is provided free by the many treatment hubs around the country. There is a Philhealth package that covers many of the expenses associated with an HIV diagnosis, especially in government-run treatment hubs.
Perhaps the best way to be safe from HIV is to be well-informed about it and understand how to prevent infection in the first place. An easy-to remember acronym has been the “ABCs” of HIV prevention, which stand for A – abstinence, B – be faithful, C – condoms. This has since been expanded to D – don’t do illicit drugs and take your good drugs (ARTs prevent transmission) and E – education. A tongue-in-cheek “F” for “FrEP” (PrEP actually), which stands for pre-exposure prophylaxis has also been added. PrEP is the newest way to prevent HIV. It entails taking two medications that are used in ART in certain situations. Not everyone qualifies for PrEP but if taken properly with adequate medical supervision, it further decreases the risk of acquiring HIV by nearly 90 percent.
HIV care and prevention in the Philippines have grown by leaps and bounds. When I came home from the US in 2008, the ART that was available then was substandard and in short supply. Thanks to the efforts of the government, civil society, activists, doctors, and especially the PLHIV themselves, access to care and treatment has substantially improved and expanded. The ART regimens we now have are on par with developed countries and provided free of charge. The 1998 AIDS Law has been revamped. It is now more responsive to the needs of PLHIV, especially in fighting stigma.
Many gaps remain, however, especially in encouraging people to test themselves for HIV. Discrimination and bias are still prevalent especially among religious fundamentalists, who would rather judge PLHIV by their diagnosis rather than act with compassion toward their fellow human beings. HIV is not a punishment from God nor is it something that only happens to bad people. HIV is an infectious disease that is caused by a virus that can infect anyone. PLHIV are people who have the right to live and have a good life as much as anybody else in this world. Each PLHIV is someone’s son or daughter, brother or sister, mother of father, life partner, friend or significant other. In this respect, we are all living with HIV. The tools exist for PLHIV to live a normal and happy life. Let’s all work together to make this happen.