Dear all on the new list,

A good topic to get us started might be the recent NY Times article (pasted
below) about low HIV prevalence in the Philippines.

Question: Is prevalence likely to remain "low and slow," or will there be an
"explosion?" And how to explain low HIV prev. rates among MSM, FSW and IDU in
the Philippines?

Edward C Green
Harvard Center for Population and Development Studies
9 Bow Street, Cambridge, MA 02138
E-mail: EGreendc@...
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Low Rate of AIDS Virus in Philippines Is a Puzzle

By SETH MYDANS

MANILA: Public health officials say they are stumped by a paradox in the
Philippines, where a very low rate of condom use and a very low rate of
H.I.V. infection seem to be going hand in hand.

AIDS-prevention efforts often focus on the use of condoms, but they are not
widely available here — and are mostly shunned — in this conservative Roman
Catholic country.

Without that first line of defense, experts can only guess at the reasons for
the low infection rate. No more than about 10,000 people are believed to be
infected with H.I.V., the virus that causes AIDS, in a population of 84
million, and the relatively low rate is not thought to be a case of
underreporting.

"It's quite perplexing," said Zahidul Huque, who heads the United Nations
team group on H.I.V./AIDS for the Philippines. "We've been talking about it a
lot and frankly, we don't know why it's low. The potential for an explosion
is there."

This is particularly so because the Philippines is far from being a country
with closed borders. About one-tenth of the population works overseas, all of
them potential carriers of disease whenever they visit home.

Experts say a lucky combination of factors may for the moment have slowed the
arrival of an epidemic, including a low ratio of customers to sex workers,
low rates of certain other sexually transmitted diseases and limited
intravenous drug use.

"There is no strong, clear-cut factor that will tell us, this is the reason
why," said Jean-Marc Olivé, the World Health Organization representative for
the Philippines. "I think it's a number of different factors adding up. I
think they are lucky, but that's not at all the way to control AIDS."

As of January, government figures showed that just 1,810 people had tested
positive for H.I.V. The United Nations office on AIDS estimates that the
actual number may be closer to 9,400 — still an extraordinarily low rate of
about 0.01 percent.

In Vietnam, for example, with almost exactly the same population, and where
the epidemic is still thought to be in its early stages, 130,000 people are
infected H.I.V., according to the United Nations.

Conversely, Costa Rica has about the same number of people with H.I.V. and
AIDS as does the Philippines. But Costa Rica is just one- twentieth the size
of the Philippines, with 3.8 million people.

Another risk factor here is that little is being done to hold back a possible
epidemic. The word condom is almost taboo in a country where the Roman
Catholic church is both conservative and politically powerful.

"Whenever you talk about condoms it's a little bit difficult," said Dr.
Olive. The government has no AIDS-awareness program of its own and restricts
the public campaigns of independent family-planning groups.

One result is that in a country where more than half the population is of
reproductive age, only 23 percent of sexually active young men say they have
ever used a condom. Only 4 percent say they use condoms regularly. Only two
out of five sex workers say they use them regularly.

Like other experts, Dr. Olive said the low number of reported infections was
not simply the result of poor record-keeping.

"It's not a reporting issue," he said. "It's a real fact that we don't
understand really why AIDS infection is so low here in the Philippines."

The most frequently cited reason is that commercial sex workers have fewer
partners than their counterparts elsewhere. The average is about four per
week, according to a new government survey. Other studies suggest that a
relatively low proportion of men frequent sex workers.

Experts say other factors may be the small number of intravenous drug users
and a low prevalence of ulcerated sexually transmitted diseases — like
syphilis and herpes — that facilitate transmission of the AIDS virus. Anal
sex also appears to be less common.

Also, most men here are circumcised and there has been speculation in the
Philippines and elsewhere that this could be a factor in preventing infe
ction.

In the small city of Angeles, where about 1,600 women work in a thriving
red-light district, the director of the health center, Dr. Teresita Esguerra,
said a mass screening last year found five women to be infected. Because they
cannot afford the drugs needed to slow the progress of the disease, she said,
the clinic can do little more than offer them information and advice.

"They are advised to still work, because they have the right to work under
Philippine law," the doctor said. "They are properly counseled and properly
guided, but we do not advise them to stop working."

She said the women are encouraged to use condoms but complain that their
customers often object and that "because of financial reasons" the women do
not insist.
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