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Paolo: Being HIV-positive as a personal struggle

Meet HIV-positive Paolo, who believes that being PLHIV is a personal journey. “No one can really gauge what PLHIVs feel except themselves. HIV is really a personal thing. At the end of the day, after you separate with the people who listen to you, the depressions would start to kick in. And every time I’m alone in my room, that’s when the tears start to fall – not because I have HIV, but the struggle I experience everyday in dealing with this,” Paolo says.

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This is part of “More than a Number”, which Outrage Magazine launched on March 1, 2013 to give a human face to those infected and affected by the Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) in the Philippines, what it considers as “an attempt to tell the stories of those whose lives have been touched by HIV and AIDS”. More information about (or – for that matter – to be included in) “More than a Number”, email editor@outragemag.com, or call (+63) 9287854244 and (+63) 9157972229.

(THIS IS PART OF A SERIES, WITH THE STORY OF PAOLO SHARED IN PARTS – ED)

He was standing on the balcony of one of the coffee shops in Tomas Morato, puffing his cigarette before he spotted, and then waved at me.

“Hi, I’m Paolo, patient H42007XXX*,” he said to me when we were face to face, introducing himself as he reached for my hand.

Several weeks back, I received an email from an unfamiliar sender, asking if I wanted to write about the “real deal of being a PLHIV in the Philippines”. Having written about the issues facing the HIV community in the Philippines, including the ARV stockout, this was not exactly uncommon.  Outrage Magazine also has a campaign – “More than a number” – that aims to give a human face to those affected by HIV.  But the following day, the same sender sent another email; and this time, it seemed more… convincing.

Dear Mr. Pascual,

I came across your contact details while browsing Outrage Magazine.

I am reaching out to you for an interview. I want to give firsthand details and experiences on what it’s like to be a PLHIV. I want to share my perspective. We can set a meeting so you can listen to my story.

Don’t get me wrong, I’m not asking anything in return, I just want to share what I know and what I have been to in the last eight years; probably, to help and inspire other PLHIVs and to educate members of the LGBT community.

Hoping for your favorable reply.

Regards,

Patient H42007XXX

WAKE-UP CALL

“I remember the time when I found out that I am HIV-positive. It was the summer of 2007. My friends and I usually get ourselves tested every six months because of the kind of lifestyle we were practicing,” Paolo recalled.

Before being diagnosed, he spent most of his nights in different LGBT places in the metro, including clubs and bathhouses. He admitted to partying, drinking, and taking recreational drugs like there was no tomorrow.

He did go to “San Lazaro to register and submit my test results. I felt that it was the right thing to do,” he said.  Paolo also admitted his status to his closest friends, even if kept it from his family.

Even after he tested positive, Paolo’s lifestyle remained as wild as usual.  “I was out every night. Because whenever I’m sober, when I’m alone and the surrounding is quiet, that’s when depression kicks in. Yes, I’m okay. Yes, I already accepted my status. But, things are not that easy. I always need a distraction to take my mind off things,” Paolo said.

After his few initial visits to the treatment hub, he stopped going for four years and only returned in early 2011, when one of his friends also tested positive and asked for his help.

“My CD4 count at that time (in 2007) was 582; it was high enough. But when I went back to the hospital in 2011, it was already 327. I was really worried,” Paolo said.

STARTING TREATMENT

When his CD4 count reached that level, he was advised by the doctors to start taking antiretroviral medications.

Paolo was willing to start the trial period of the treatment, but one of the hub’s policies at that time was for a patient to have a treatment partner before they allow and give them the medicines.

“I have no one to ask,” Paolo said.

He was living on his own that time.

“And although my friends knew my status, I didn’t want them to go through the endeavor I was going through,” he recalled.

So he convinced the doctors to allow him to start the treatment on his own and assured them that he would comply with all the requirements of the hub.  Paolo was made to sign a waiver, indicating that whatever happened to him, the treatment hub or attending doctors will not be held liable.

“I was given two weeks’ worth of Lamivudine/Zidovudine and Nevirapine. The doctors also gave me a list of allergy-causing food and was asked to avoid them for three months,” Paolo said.

During the first few days of intake, Paolo started feeling pain and was feverish.

“The doctors explained the possible initial side effects of the ARVs; but to actually feel it first hand, it was like hell. Two days in, my whole body was in pain. My fever was rising every day. I wasn’t allowed to take Paracetamol. I wanted to stop taking the medications, but I know it wouldn’t do any good,” Paolo said.

He lost almost 30 lbs after one week. His fever played from 39°C to 43°C, and patches of red marks also started to appear in different parts of his body.

“I was very weak. I called the treatment hub and told them about my condition. I was asked not to stop taking the ARV meds and finish the two-week trial. But before I was able to reach the 14th day, I was experiencing unbearable headaches and muscle pain, it felt like I was going to die,” he said.

The first thing the following day, he went to the hub and waited for the doctor.

He was injected with a high dose of Iterax.

“That morning, the antihistamine that was given to me was really strong. I took the train on my way home. It was really difficult. It was a mix of headache, nausea, and muscle pain,” Paolo recalled.

After one week, he was asked to go back to the hub. He was given another set of ARVs.

“Good thing they shifted my medication to Efavirenz. Even if I feel groggy every time I take it, it’s more tolerable than Nevirapine,” he added.

FEELING LOW

“I remember when I lost weight and when red patches started to appear on my skin, I felt so low. I couldn’t see myself anymore. I wore a jacket all the time so people would not see how ugly I WAS becoming,” Paolo said.

He was also making every possible effort to act and look normal at work, even if it was close to impossible.

“In the office, I was always blank and not functioning normally. Some of my officemates even started teasing me when they noticed the red patches on my skin. I felt really down, I almost felt suicidal,” he said.

Though his friends communicated with him everyday to check his condition, for Paolo, it was not enough.

“Even if I have friends who were there for me, the feeling was so impalpable. It was unexplainable. No one can really gauge what PLHIVs feel except themselves. At the end of the day, after you separate with the people who listen to you, the depressions would start to kick in. And every time I’m alone in my room, that’s when the tears start to fall – not because I have HIV, but the struggle I experience everyday in dealing with this,” Paolo shared.

He also joined different organizations that cater to the needs and welfare of PLHIV, but that didn’t help him either.

“Those support groups, yes, they’re doing a superb job, no doubt about that. But in reality, it’s not them who can and will help you because they don’t really know what you’re feeling, HIV is really a personal thing. Support groups… I have been involved with three of them, and they have not really offered enough support particularly when you’re experiencing a chronic type of depression. Sometimes, crying all by yourself while you’re drunk is better than repeating your story over and over again to a group of people,” Paolo ended.

*EXACT PATIENT CODE WAS REMOVED AS REQUESTED BY THE INTERVIEWEE TO PROTECT HIS PRIVACY

Living life a day at a time – and writing about it, is what Patrick King believes in. A media man, he does not only write (for print) and produce (for a credible show of a local giant network), but – on occasion – goes behind the camera for pride-worthy shots (hey, he helped make Bahaghari Center’s "I dare to care about equality" campaign happen!). He is the senior associate editor of OutrageMag, with his column, "Suspension of Disbelief", covering anything and everything. Whoever said business and pleasure couldn’t mix (that is, partying and working) has yet to meet Patrick King, that’s for sure! Patrick.King.Pascual@outragemag.com

Op-Ed

I may be HIV+ but that still doesn’t mean I’ll sleep with you

This is something every PLHIV needs to learn. That we are still “worth it”. Forget these notions of you being a “damaged good” or a “dirty person” or banalities given us along those lines. Because my HIV status is just one facet of my outrageous (and fabulous) personality; it does not define me.

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Photo by lalesh aldarwish from Pexels.com

“I’m HIV-positive.”

That was the short sentence I remember telling this guy I used to date.

Okay – to backtrack – I met a guy while I was in Northern Mindanao. We dated for a while, and – at least I thought – things between us went smoothly for a while. I’d say he wasn’t bad-looking even if he looked somewhat common. He had one of those “if you stay long enough, I can teach myself to maybe even like you” face.

And then one night, we became more intimate than the usual. So I had to stop what we were doing (before we progressed further). And then – after prepping him up by first discussing with him his views about HIV and people living with HIV – I told him I had something important to tell him (if we were to advance what we had).

Thus that short sentence.

His face immediately changed; from what I saw was longing to… shocked. He couldn’t even say a word. And when he was finally able to utter a word, it was just to tell me that “I forgot I had to be elsewhere.”

The alibi was lame. But what made it more insulting was that I wasn’t even that into him to begin with; he was just a possible lay (if it came to that)

But that moment taught me two important things.

On one hand, how the sexuality of so many PLHIVs are tempered by their status.

I have frequently heard of medical practitioners who tell PLHIVs to “already stop having sex now that you’re HIV-positive; dadami pa kayo (you’d abet in increasing the number of PLHIVs)” – all too obviously unaware of safer sexual practices and U=U, among others. Worse, this sentiment is shared by a lot of PLHIVs themselves, who see their status as a “punishment”, and the only “cure” is to stop having sex altogether. Oh, please!

On the other hand, recognizing that being sexual doesn’t disappear (and doesn’t need to vanish) with being HIV-positive, there seems to be this supposition of PLHIVs being “desperate”.

That guy I dated, for instance, had every right NOT to have sex with me (it’s called power over one’s body); but that he had to lie just to get away from me was – to admit the truth – not only discourteous but even insulting. I suppose particularly because… I wasn’t even that into him.

Here’s the thing: Me living with HIV means just that – that I have HIV. But it doesn’t mean that I’ve lost my (yes!) sexual appetite and (for that matter) taste/preferences/standards on who to do it with.

And I believe this is something every PLHIV needs to learn. That we are still “worth it”. Forget these notions of you being a “damaged good” or a “dirty person” or banalities given us along those lines. Because my HIV status is just one facet of my outrageous (and fabulous) personality; it does not define me. And if (some) guys can’t see that, well…

Because remember dearie, just because I am HIV-positive still doesn’t mean I’ll sleep with you.

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POZ

CDC in the US releases recommendations for Covid-19 vaccine for PLHIVs

According to the CDC, “adults of any age with certain underlying medical conditions are at increased risk for severe illness from the virus that causes Covid-19.” It added that “mRNA COVID-19 vaccines may be administered to people with underlying medical conditions provided they have not had a severe allergic reaction to any of the ingredients in the vaccine.”

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Photo by Towfiqu barbhuiya from Canva.com

With the Department of Health (DOH) still not releasing guidelines re vaccinations in the Philippines including of Filipinos living with HIV, eyes are turning – instead – to international bodies that already released recommendations for the same. One such body, the Center for Disease Control and Prevention (CDC) – released in end-2020 its “Vaccination Considerations for Persons with Underlying Medical Conditions”.

According to the CDC, “adults of any age with certain underlying medical conditions are at increased risk for severe illness from the virus that causes Covid-19.” It added that “mRNA COVID-19 vaccines may be administered to people with underlying medical conditions provided they have not had a severe allergic reaction to any of the ingredients in the vaccine.”

The CDC noted that PLHIVs were actually included in clinical trials, but “safety data specific to this group are not yet available at this time.” It saw fit to stress this point: “Information about the safety of mRNA COVID-19 vaccines for people who have weakened immune systems in this group is not yet available.”

Nonetheless – and this is worth stressing – because “PLHIVs and those with weakened immune systems due to other illnesses or medication might be at increased risk for severe Covid-19… they may receive a Covid-19 vaccine.”

Aside from v=being aware of the potential for reduced immune responses to the vaccine, those with weakened immune systems (including PLHIVs) should continue following all current guidance to protect themselves against Covid-19.

  • Wearing a mask
  • Staying at least six feet away from others
  • Avoiding crowds
  • Washing hands with soap and water for 20 seconds or using hand sanitizer with at least 60% alcohol
  • Following (CDC) travel guidance
  • Following quarantine guidance after exposure to Covid-19
  • Following any applicable workplace guidance
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POZ

Risk of developing cervical cancer is six times higher in women with HIV

Cervical carcinomas are usually caused by infections with Human papillomavirus (HPV), which are sexually transmitted just as HIV is. Based on the results of a new study, it can be assumed that an infection with HIV represents a risk factor for an infection with HPV.

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The risk of developing cervical cancer is six times higher in women who are infected with HIV.

This is according to a study from the TUM School of Medicine’s Center for Global Health and the chair of Epidemiology at the TUM Department of Sport and Health Sciences – “Estimates of the Global Burden of Cervical Cancer Associated with HIV” – that was published in the The Lancet Global Health.

According to WHO statistics, cervical cancer is the fourth most common type of cancer for women. In 2018 an estimated 570,000 women worldwide were diagnosed with cervical carcinoma, with approximately 311,000 of these women dying.

On the other hand cervical cancer, usually caused by Human Papillomavirus (HPV), is also one of the most successfully preventable and treatable types of cancer, as long as it is detected at an early stage and treated effectively.

Cervical cancer is at the same time the most frequently detected cancer for women who live with HIV, since their immune systems are weakened by the HIV infection.

Systematic review and meta-analysis of 24 studies

The lead authors Dr. Dominik Stelzle (Center for Global Health and Chair of Epidemiology) and Dr. Luana Tanaka (Chair of Epidemiology) conducted a systematic review as well as a meta-analysis of a total of 24 studies from the years 1981 to 2016, in which 236,127 women with HIV from four continents (Africa, North America, Asia and Europe) participated.

These studies covered a total of 2,138 cervical carcinoma cases. The results were linked with data from UNAIDS on worldwide HIV infection and with data on cervical carcinoma from the International Agency for Research on Cancer (IARC), the WHO’s Cancer Research Center, and then evaluated.

“Until now there have only been estimates from countries with high net income levels,” says Dr. Stelzle. “That’s why we looked at the figures on global incidence of cervical carcinoma in connection with an HIV infection and included estimates for countries with low net incomes. In most parts of the world the numbers are under five percent. In some countries however we’re talking about well over 40 percent of cases.”

Risk is six times higher for women with HIV

The objective of the study was to calculate the share of women living with HIV among the number of women with cervical cancer. The authors found that 5.8 percent of all new cervical cancer cases worldwide in the year 2018 were diagnosed for women with an HIV infection. This is equivalent to 33,000 cases a year, 85 percent of which occurred in Sub-Saharan Africa.

Furthermore, based on their results the team was able to show that women with HIV have a sixfold higher risk of developing cervical cancer than women without HIV infection.

“The association between cervical carcinoma and HIV is plausible,” says Prof. Andrea S. Winkler, co-director of the Center for Global Health. “Cervical carcinomas are usually caused by infections with Human papillomavirus (HPV), which are sexually transmitted just as HIV is. Based on our results it can be assumed that an infection with HIV represents a risk factor for an infection with HPV.”

Based on the results, the TUM authors determined that women with an HIV infection have a significantly higher risk of developing cervical cancer. They also pointed out that this means that HPV vaccinations and early-stage cervical carcinoma screenings are of particular importance.

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How the vaginal microbiome may affect HIV prevention

With no effective vaccine for HIV, alternative strategies such as pre-exposure prophylactic (PrEP) drugs are necessary to prevent transmission. PrEP drugs are highly effective in preventing the acquisition of HIV infection in men, but they are much less effective at preventing HIV infection in women.

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Photo by Timothy Meinberg from Unsplash.com

Healthy Lactobacillus bacteria in the vagina are critical for women’s health, but the accumulation of additional bacterial genera can imbalance the vaginal ecosystem. Such an imbalance may result in bacterial metabolism of drugs designed to prevent HIV infection, thereby decreasing their effectiveness and enhancing risks to women.

This is according to a study published in the open-access journal PLOS Pathogens by Dr. Nichole Klatt of the University of Minnesota Medical School, and colleagues.

With no effective vaccine for HIV, alternative strategies such as pre-exposure prophylactic (PrEP) drugs are necessary to prevent transmission. PrEP drugs are highly effective in preventing the acquisition of HIV infection in men, but they are much less effective at preventing HIV infection in women.

Recent evidence demonstrates that vaginal microbial communities are associated with increased HIV acquisition risk and may impact PrEP efficacy. To better design and conduct clinical studies assessing HIV prevention in women, it is essential to understand how microbes in the female reproductive tract affect therapeutic drug levels.

In the new study, Klatt and her colleagues investigated how vaginal bacteria alter PrEP drug levels and impact HIV infection rates using cervicovaginal lavage samples from women with and without bacterial vaginosis (BV) – a highly common syndrome in women that is caused by bacteria that can induce itching, discharge and discomfort, and has been associated with increased sexually transmitted infections and negative reproductive tract outcomes in women.

However, current treatments for BV frequently fail and recurrence is common. The researchers found that bacteria associated with BV – but not healthy Lactobacillus bacteria – can metabolize PrEP drugs and may potentially reduce PrEP efficacy due to reduced levels of available preventative drug. According to the authors, better measurements and interventions for bacterial vaginosis will be critical for improving the efficacy of HIV prevention efforts in women.

Dr. Klatt highlights, “women’s health, and factors that contribute to health and disease prevention in women are grossly under studied. This study demonstrates the critical need to develop better treatments for bacterial vaginosis, and in general, to promote more studies of women’s health.”

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POZ

Dep’t of Health dispenses newer HIV drug in the Phl

The Department of Health (DOH) is introducing LTD (lamivudine, tenofovir, dolutegravir) in the country.

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Took them long enough…

Xander (not his real name) has been HIV-positive since December 2012; and from the very first time he took his antiretroviral (ARV) medicines, “it has always been LTE (for lamivudine, tenofovir, efavirenz),” he said.

There have been adverse side effects – e.g. “At night, my dreams are so vivid I am unable to distinguish what’s real or what’s not,” Xander said, adding with sadness that “the doctor just told me to ‘Drink more water!’ as if that’d solve my problem.”

Those like Xander may now have their ARVs changed, with the Department of Health (DOH) introducing LTD (for lamivudine, tenofovir, dolutegravir) in the country.

This December, the Global Fund for treatment of people living with HIV (PLHIV) donated 197,260 bottles of LTD. The stock is being managed by the DOH’s Disease Prevention and Control Bureau – National HIV, AIDS and STI Prevention and Control Program.

The first tranche of 98,630 bottles were already allocated to various Centers for Health Development, while the last tranche (98,630 bottles) are expected to arrive in the country before the end of the year.

In an advisory signed by Undersecretary of Health Dr. Myrna Cabotaje, the DOH stated that based on the National Plan for LTD Introduction, the new ARV will be introduced from now until December 2021. These sub-populations of PLHIVs can benefit from LTD:

  • ART-naive adults, adolescents and children (30 kg and above), excluding TB patients on rifampicin-based regimen
  • PLHIVs on LTE with severe adverse events (dizziness, insomnia, abnormal dreams, anxiety, depression, mental confusion, convulsions, hepatoxicity, severe skin and hypersensitivity reactions and gynecomastia)
  • Patients with treatment failure to zidovudine (AZT) and abacavir (ABC)-based regimens

Xander knows he has to broach his concerns to the doctor in his treatment hub again to ascertain if he can shift from LTE to LTD. And “the DOH really took its time,” he mused, adding that hopefully, “this is just one of the steps wherein Filipino PLHIVs actually already start being able to access life-saving HIV meds already widely available in more developed countries.”

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Even with limited HIV services due to Covid-19, Phl reports 21 new HIV cases per day

Even with Covid-19 affecting the delivery of HIV-related services, the country is still reporting 21 new HIV cases per day. In October 2020, there were 735 new HIV-positive individuals reported to HARP.

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AIDS: The other pandemic.

Even with Covid-19 affecting the delivery of HIV-related services – that were already problematic even pre-pandemic – the country is still reporting 21 new HIV cases per day. This is according to the latest (for October 2020) report from the HIV/AIDS & ART Registry of the Philippines (HARP) of the Department of Health’s (DOH) Epidemiology Bureau.

Specific to October 2020, there were 735 new HIV-positive individuals reported to HARP; and 21% (153) of them had clinical manifestations of advanced HIV infection at the time of testing.

MEN IN MOST CASES

A big chunk of the newly infected are still male; and not just members of the LGBTQIA community, it must be emphasized.

Ninety-six percent (704) of the reported new cases were male. The median age was 28 years old (age range: 3-60 years old). More than half of the cases (52%, 379) were 25-34 years old and 28% (204) were 15-24 years old at the time of diagnosis.

More than a third (40%, 295) were from the National Capital Region (NCR). Region 4A (20%, 146), Region 3 (16%, 121), Region 6 (7%, 54), and Region 12 (5%, 36) comprised the top five regions with the most number of newly reported cases for this reporting period, together accounting for 88% of the total cases.

Sexual contact remained as the predominant mode of transmission or MOT (99%, 725). Among the newly reported cases infected through sexual contact, 60% (437) reported transmission through male-to-male sex, 28% (200) through males who have sex with both males and females, and 12% (88) were through male-to-female sex.

There were nine cases (1%) that had no data on mode of transmission.

YOUTH AND HIV

Even if there are less HIV services, trends noted in the past continue – e.g. youth continue to be greatly affected by HIV.

In October 2020, 204 (28%) cases were among youth 15-24 years old; and 94% of them were male. Almost all (99%, 201) were infected through sexual contact (20 male-female sex, 136 male-male sex, 45 sex with both males & females), and 1% (3) had no data on the MOT.

Children (<10) and adolescents (10-19) were also infected.

There were 27 newly diagnosed adolescents. Of these, six were 15-17 years old and 21 were 18-19 years old. All newly reported adolescent cases were infected through sexual contact (five male-female sex, 20 male-male sex, two sex with both males and females ).

Further, one child was diagnosed with HIV in this reporting period was infected through vertical transmission (formerly: mother-to-child transmission).

HIV AMONG OFWs

Fifty-four Filipinos who worked overseas within the past five years, whether on land or at sea, were newly diagnosed in October 2020. They comprised 7% of the total cases for this period. Of these, 93% (50) were male.

All of the male cases were infected through sexual contact (eight male-female sex, 27 male-male sex, and 15 sex with both males and females).

The ages of male OFWs ranged from 23 to 54 years (median: 33 years). More than half (54%, 27) of the male cases were 25-34 years old at the time of testing and 36% (18) were 35-49 years old. Among the four female OFWs, all where infected through male-female sex.

Seventy-five percent (3) were 25-34 years older at the time of testing and 25% (1) were 35-49 years old. The age range among diagnosed female OFWs were from 27 to 35 years (median: 32 years old).

PREGNANT WOMEN LIVING WITH HIV

Still in October, 13 were reported pregnant at the time of diagnosis. Five cases each were from NCR and Region 4A; and one case each from Regions 3, 10 and 12.

Reporting of pregnancy status at the time of diagnosis was included in the HARP only starting year 2011. From January to October 2020, there were 85 HIV positive women reported pregnant at the time of diagnosis. Of these, 35% (30) were from NCR, 22% (19) were from Region 4A, 16% (14) were from Region 3 and 27% (22) were from the rest of the country. The age of diagnosis ranged from 15 to 45 years old (median age: 25).

TRANSACTIONAL SEX

In October 2020, 13% (93) of the newly diagnosed engaged in transactional sex. Ninety-nine percent (92) were male and aged from 19 to 57 years old (median: 30 years). Fifty-two percent (48) of the males reported paying for sex only, 29% (27) reported accepting payment for sex only and 18% (17) engaged in both. Further, there was one female aged 23 years old who had engaged in transactional sex and was reported to have accepted payment for sex only.

People who engage in transactional sex are those who reported that they either pay for sex, regularly accept payment for sex, or do both. Reporting of transactional sex was included in the HARP starting December 2012.

TREATMENT FOR PLHIVs

In October 2020, there were 579 patients who were initiated on ART. The median CD4 of these patients upon enrollment was 153 cells/mm3.

To date, a total of 47,013 PLHIVs are on ART. This is only a little more than half of the total 81,169 HIV cases in the country as of end-October.

Most (96%) of those using ART are males. The age of reported cases ranged from 1 to 79 years (median: 31 years old). Ninety-five percent were on first line regimen, 4% were on second line, and 1% were on other line of regimen.

DEATHS AMONG PEOPLE WITH HIV

Perhaps the number of deaths among PLHIVs highlight the under-reporting in the country as far as HIV is concerned. Since data was gathered in January 1984, only 4,444 deaths were reported, and the real figure may be much higher though affected by both under- and non-reporting.

In October 2020, specifically, there were 248 reported deaths due to any cause among PLHIVs. Ninety-six percent (238) were males. One case (<1%) was less than 15 years olds at the time of death, 29 (12%) cases were 15-24 years olds, 109 (44%) were 25-34 years olds, 79 (32%) were 35-49 years olds, and 27 (11%) were 50 years and older.

Ninety-five percent (235) of the cases were reported to have acquired the infection through sexual contact (37 through male-female sex, 124 through male-male sex, 74 through sex with both males and females), 3% (7) through sharing of infected needles, and <1% (1) were infected through mother and child. Five (2%) reported deaths had no data on MOT.

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