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Are we there yet? Reaching global goals for HIV in Asia and Pacific Regions

Treatment approaches should also be within context of a country’s culture. Any approaches for it to work must be culturally appropriate. HIV and drug use are indeed global issues but unfortunately, successful approaches in first world countries does not automatically translate to the same level of success in third world countries. Take the Philippines as an example. MSM is an issue that is still taboo in many places, particularly in very remote places; therefore, collecting accurate data will remain questionable. Studies will always be one sided for not all views will be collected. Drug program and HIV intervention as mentioned, are treated separately for the reason stated above. Are we there yet? Certainly not. But until culturally appropriate treatment strategies could be devised, HIV will always remain a stigma and the 90-90-90 target will remain a long way from achievement.

Presentation by Maria Dulce Natividad

Maria gave a disturbing presentation about the current state of HIV prevention work in the Philippines. There has been a frightening shift in the landscape since President Duarte took the reins in June 2016.

Between 2010 and 2016 the Philippines has seen a doubling of HIV infections from 4300 to 10500. Maria noted that prior to that time progress on HIV prevention in the Philippines was “low and slow”. While most of the rise is seen to be amongst young MSM, there is also concern for those who inject drugs. Prevention for this group under the current Government will be very difficult.

After taking office President Duterte declared a ‘war on drugs’ , which has been marked by harsh condemnation of drug users and Presidential ‘permission’ to punish and kill drug users. Maria presented several quotes from the president, which including the words “free to kill idiots” (IV drug users). The impact on the ground was the beginning of extra judicial killings which have led to an estimated 13000 deaths. Maria described this as a “shoot first, ask questions later” approach.

She noted that the political message represented a harnessing of fear and social discontent, with its roots in social inequality. It has enabled the institutionalisation of fear through promises of cleaning up society. Maria argued that for Duterte it has led to a consolidation of political support.

The resulting discrimination means that drug users have been driven further into the shadows, with people avoiding health care because they fear for their safety. Harm reduction has become much more difficult. Programs such as clean needle distribution have been discontinued, drug use is poorly documented, and activists/advocates are afraid to get involved.

Drug use and HIV interventions are treated separately, so there is no cross linking.

The situation in prisons is very concerning, with greater overcrowding and a subsequent rise in health issues, which is likely to include blood borne infections.

Overall it appeared to be a grim picture which does not present much room for optimism, however Maria discussed some areas of hope. While dialogue is not possible nationally, change may be initiated at the community level. Some communities and smaller organisations are stepping in to help despite the risks.

IV drug users have the most to fear in the current climate. Perhaps Australian health workers and their peak bodies can find ways to support those communities which are brave enough to help people affected by these depressing government policies, and through this keep alight the flame for HIV prevention. 

Joint Symposium: Are we there yet? Reaching global goals for HIV in Asia and Pacific Regions

HIV response in PNG. Are key populations being reached?

Dr Angela Kelly-Hanku, Senior Research Fellow, Papua New Guinea Institute of Medical Research /Kirby Institute, UNSW, Sydney Papua New Guinea

An interesting discussion around whether key populations are being reached in terms of the HIV response within Papua New Guinea (PNG).

Dr Kelly-Hanku explained we need to ‘unpack’ the term key population and posed the question of exactly ‘who’ are the key populations.

Sexual identity: How one claims their sexual identity is changing in PNG. From bisexual to gay to men who have sex with men (MSM), to men of diverse sexualities.

Attraction: Who one is attracted to; only women, only men or mostly women for example, however this does not mean they are having sex with who they are attracted to.

Sexual behaviour: Who did they last have sex with? Male, female and so on.

These complexities around sexual identity may indeed be the reason why some key populations are not being reached in PNG, claiming the picture is far more complicated than people wanted to know.

Dr Kelly-Hanku suggests we learn how to work with it, through the different layers of diversity, attraction and ethnicity. Much more work needs to be done in order to reach the global targets for HIV and increase levels of testing and treatment, however PNG is up for the challenge, showing it can be done, where some financial donors have said no!

Perhaps one of the more applicable talks to my experience in Timor was that given by Angela Kelly-hanku on challenges reaching key populations.

In PNG its the church groups who often provide the most stable centers to operate health interventions (different from in Timor), and these have been the platforms from which international health programs have carried out their work.

The talk highlighted just how difficult it is to define the 'key populations', in that many who present to these facilities do so as they want non-judgmental care, where they won't be labelled as MSM, FSW and so on. I do wonder if its similar to the situation in Timor, where the largest HIV clinic is run by a private NGO, as foreign staff (and possibly church groups) are less likely to know the patient and their family. But defining key population can be so much more difficult... An interesting chart revealed 20% of MSM in PNG didn't report being attracted to men, and 40% reported being attracted to both men and women. We may see a fairly similar pattern in Timor once again, where a high percentage of the MSM (>50%) also have female partners. This could be related to the horrendous level of stigma and discrimination against them.

However the ultimate answer to the question are we reaching the key populations was revealed towards the end of the presentation with confronting statistics revealing 60% of the MSM in PNG have never been tested, and 32% of the FSW have never been tested. So No is the answer.

I can't imagine Timor is any better with the horrendous supply chain issues encountered over the past year...

Joint Symposium: Are we there yet? Reaching global goals for HIV in Asia and Pacific Regions

Health vulnerabilities, human rights and the war on drugs in the Philippines.

Jonas Bagas, Programme Officer, Asia Pacific Council of AIDS Service Organisations, Bangkok, Thailand

The focus of this session was to discuss how our neighbours are meeting global goals for HIV, in terms of leaving no one behind in the aids epidemic.

The ongoing fight to end the public health threat of AIDS concerns all of us. The epidemic does not respect borders, whether it be new migrants that have acquired AIDS overseas and settle in Australia or tourists visiting overseas and returning with an acquired infection.

The Philippines in particular has one of the most explosive HIV epidemics in the Asia and Pacific Region. High levels of discrimination and stigma towards key populations such as men who have sex with men (MSM) continue to exist.

Are the Philippines there yet, will they meet the Fast-track target of 90-90-90 by 2020? No, Jonas informs. In fact, targets are way off with 260 000 new HIV infections in 2016 alone.

141% increase in HIV infections was reported since 2010, particularly among key populations and young MSM. Gay men are suffering and dying in silence, fearful of accessing healthcare.

Barriers hindering progression towards targets include; poor knowledge, increase prevalence of STIs, chem sex and low-level condom use.

Prevention targets are also not being met. ½ of MSM, people who inject drugs and sex workers are not even aware of their HIV status. Treatment targets are also off track.

The Philippines are not there yet, Jonas states they will not get there by 2020 or by 2030.

Why? Political struggles, human rights violations and the war on drugs are all key contributors that need urgent attention. Politics are core of the response.

Take home message was we need to work towards zero discrimination, uphold human rights and continue the fight to ends aids for all.