CLINICAL MATTERS

Almost every December, I am the adult infectious diseases supervising consultant assigned to the Medical Intensive Care Unit (MICU) at the Philippine General Hospital. I personally prefer doing charity MICU instead of the ward service because it means that I can concentrate on fewer patients albeit with very challenging medical problems. These patients typically have many comorbid illnesses and most of them are elderly and frail. Typical infections include pneumonia, complicated urinary tract infections, and sepsis.

On the first day that I made rounds with the trainees, I was shocked to note that there was an unusually high number of young men with HIV occupying many of the ICU beds. The numbers reminded me of the early days of my practice in 2008 when I first joined the UP-PGH faculty and ran smack into the initial surge of new HIV cases in the Philippines. I was distressed that the progress we had made was coming undone. 

Throughout my stay in medical school at the University of the Philippines College of Medicine from 1996 to 2001, I only saw two HIV patients in the wards and no one wanted to touch them. This was due to ignorance and stigma which incited fear towards these patients. They both had Acquired Immune Deficiency Syndrome or AIDS, which is the result of long-standing HIV infection which eventually destroys the immune system. The HIV epidemic in the Philippines at that time was described as “low and slow.” Many debunked stereotypes about HIV and AIDS still existed and there was no good antiretroviral treatment readily available. It was unclear why our HIV numbers were so low when other sexually transmitted infection rates were similar to neighboring countries in the region. There was even a hypothesis of some unknown genetic trait that protected Filipinos, but this was never proven. The truth was that we just got lucky and the numbers eventually caught up with us.

When I first started teaching at UP-PGH back in 2008 after completing my infectious diseases training in the United States, I was alarmed at the increasing number of young people who were being admitted to the hospital with AIDS. Most were in very bad shape and ended up dying even before we could get them on antiretrovirals. I remember a particularly bleak Christmas day when a young medical student under my care who had recently been diagnosed with HIV and Cryptococcus (a type of fungus) meningitis suddenly died without warning. Due to the immense pressure building up in his head from the infection, his brain was pushed down into his spinal cord which caused his untimely demise. It was these young men who were dropping dead in the prime of their lives that pushed me into HIV advocacy and shifted my research work from tropical medicine to HIV. I concentrated on HIV molecular epidemiology to figure out what was causing the unprecedented rise in cases. Our research findings uncovered a shift in the predominant subtype of HIV in the Philippines from subtype B to the more transmissible and aggressive CRF01_AE as a major factor in the alarming rise in new HIV infections.

People with HIV don’t usually die due to HIV. They die from opportunistic infections that occur and become uncontrolled as HIV ravages the immune system. Aside from the fungal meningitis that killed my medical student patient, other deadly opportunistic infections include Pneumocystis jirovecii pneumonia (PCP), cerebral toxoplasmosis, central nervous system lymphoma, Kaposi’s sarcoma, and TB meningitis. Some patients, because of their extreme immunosuppression, end up with two or more of these opportunistic infections which can very quickly kill them. Seeing these kinds of patients is an indication that people are not being diagnosed in a timely fashion.

Prior to the availability of widespread testing, PLHIV were typically diagnosed with HIV when they already had opportunistic infections. Unfortunately, that usually means that the HIV infection has progressed to AIDS and the patient will likely die within a year unless antiretrovirals are started. Starting effecting ARVs early prevents PLHIV from progressing to AIDS, as long as they continue to take their meds and do not develop resistance. As more advocates and the government responded to the alarming situation, antiretrovirals became less toxic and more available. We got better at diagnosing HIV earlier and starting antiretrovirals regardless of the stage of the disease. Fewer and fewer PLHIV ended up in the ICU and things started to get much better. Many young people that we started on ARVs recovered quite well and were able to get their lives back. A few even immigrated abroad and were quite successful.

Unfortunately, the Covid-19 pandemic disrupted our local HIV programs, and a lot of PLHIV were lost to follow-up and stopped taking their meds. After we reopened in 2022, a substantial number of PLHIV did not come back and their conditions deteriorated. We saw a sharp increase in the number of patients coming in with AIDS-defining opportunistic infections shortly after the pandemic ended. These patients included both newly diagnosed and those with PLHIV who were unable to return to the clinic. The number of newly diagnosed cases of HIV had artificially gone down during the pandemic since people were not able to access testing, but we knew that they were still out there. True enough, in 2023 the number of daily cases not only went back to pre-pandemic levels but overshot and exceeded them.

Fortunately, we have a lot more resources available in 2024 compared to 2008. We have designer antiretrovirals at par with those used as first line in the US and other developed countries. Treatment is free. Testing is becoming more and more accessible. PrEP (pre-exposure prophylaxis) services are taking off, and long-acting PrEP with cabotegravir and lenacapavir will likely be game changers if properly deployed. The current surge in cases is a strong reminder that even with improving resources, we can easily lose our momentum and fall behind when disruptions take place. ARVs restore the immune system and prevent infection. Stopping ARVs means more AIDS cases and more transmission. Defeating HIV in the Philippines is a long-term commitment and we cannot afford to take our foot off the gas pedal. Otherwise, many more young Filipinos will be infected and will lose their lives.