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From the Editor

Why aren’t we talking about ‘undetectable = untransmittable’ in the Philippines?

With PrEP about to be introduced in the Philippines, Michael David dela Cruz Tan notes that other prevention approaches should not be neglected – i.e. getting PLHIVs into treatment, since evidence now shows that those taking HIV medication as prescribed and have had an undetectable viral load for over six months cannot pass on HIV with or without a condom.

So the Philippines is finally looking at offering pre-exposure prophylaxis (PrEP), now one of the HIV prevention methods gaining (even more) popularity particularly in Western countries. PrEP – recommended for people who are HIV-negative but have high risk for HIV transmission, e.g. persons who inject drugs, men who have sex with men, sex workers – makes use of a combination of two HIV medicines (specifically tenofovir and emtricitabine; sold under the name Truvada) to be taken daily to reduce HIV risk by 92% to 99%.

There are still numerous issues surrounding PrEP, both globally and, more specifically, as will be noted with its use in the Philippines.

For instance, there’s the drug “dependence” that’s basically making (yet again) pharma companies richer – i.e. kudos to Gilead Sciences for coming up with Truvada, but at the same time, let’s not pretend this is (just) out of goodwill, as much as it is for the company to profit from HIV.

In 2014, I encountered a female HIV activist in New York who lamented that a cure for HIV may not see the day, considering the money pharmas get from it. Her way of seeing isn’t surprising, considering that – for instance – the profit of Gilead from HIV product sales in 2007 reached $3.14 billion, an increase of 48% compared with a year earlier. Note that in 2007, the HIV drug market was worth $6 billion, growing to $11 billion in 2015, according to market analysis firm Datamonitor.

Another issue worth considering is how PrEP may encourage people to practice to be unsafe again (i.e. stop using condoms). Yes, we know that PrEP is recommended to be used WITH other safer sexual practices; but let’s stop pretending that there are PrEP users who stop doing so (for instance, check THIS: STI incidence is also high among PrEP users in “real world” settings).

And then, of course, there’s access to PrEP – e.g. In the Philippines, will this be covered by PhilHealth? With the roll-out focused on men who have sex with men, will this be made available to women in serodifferent relationships? How will those in far-flung areas be able to access PrEP?

Don’t get me wrong: Providing options (as many as possible) re HIV prevention is not only good, but what should be rightfully done.

But this is why, beyond PrEP, I am surprised that there’s no talk in the Philippines about “undetectable = untransmittable”.

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This is not exactly new – e.g. In 2011, a study (HIV Prevention Trials Network or HPTN 052) showed that early initiation of antiretroviral treatment in PLHIVs with a CD4 count between 350 and 550, reduced HIV transmission to HIV-negative partners by 96%. The final study results, announced in 2015, found that no participant with a fully suppressed viral load infected his/her long-term HIV-negative partner.

The World Health Organization already recommended in 2013 that antiretroviral treatment be offered to all PLHIVs to reduce HIV transmission.

Numerous experts in the field already agree on this, e.g.:

“We can now say with confidence that if you are taking HIV medication as prescribed, and have had an undetectable viral load for over six months, you cannot pass on HIV with or without a condom.”
Dr. Michael Brady, Medical Director, Terrence Higgins Trust

“If people are taking their pills reliably and they’re taking them for some period of time, the probability of transmission in this study is actually zero.”
Dr. Myron Cohen, Chief, Division of Infectious Diseases, UNC School of Medicine, North Carolina, USA; Principal Investigator, HPTN 052

“Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex…there were no documented cases of within-couple HIV transmission” among 58,000 condomless sex acts.
Reporting on PARTNER study in JAMA – Dr. Alison Rodger, Dr. Valentina Cambiano, Tina Bruun, et al.

There is even a consensus statement on this.

This is worth stressing in the Philippines because, as of May 2016, the country already had 34,158 total reported cases of HIV infection. But note that Filipinos living with HIV who are on anti-retroviral therapy (i.e. those who are taking meds) only number 14,356.

Meaning, here’s ANOTHER HIV prevention approach that isn’t given the spotlight it (also) deserves.

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The way I see it, it shouldn’t be either/or; it should be ALL steps ought to be taken to face HIV and AIDS. So that the introduction of PrEP may be good, but at the same time, getting PLHIVs into treatment should also NOT be neglected (e.g. to start, allocate funds for the promotion of this, too!). By the way, this could also deal with stigma and discrimination being faced by PLHIVs…

Sometime in 2012, while I was conducting an interview in one of the major treatment hubs in Metro Manila, I witnessed a medical professional tell a PLHIV to “stop having sex na (already) since, with your HIV, makakahawa ka lang (you will just infect others)”. Yes, she was insensitive, self-righteous and… you can come up with your own criticisms here. But – for me even then – she was also deplorable because of her ignorance. And yet this very type of looking at PLHIVs will continue so long as the “undetectable = untransmittable” continues to not be emphasized…

The founder of Outrage Magazine, Michael David dela Cruz Tan completed BA Communication Studies from University of Newcastle in NSW, Australia; and Master of Development Communication from the University of the Philippines-Open University. He grew up in Mindanao (particularly Kidapawan and Cotabato City), but he "really came out in Sydney" so that "I sort of know what it's like to be gay in a developing, and a developed world". Conversant in Filipino Sign Language, Mick can: photograph, do artworks with mixed media, write (DUH!), shoot flicks, community organize, facilitate, lecture, and research (with pioneering studies under his belt). He authored "Being LGBT in Asia: Philippines Country Report", and "Red Lives" that creatively retells stories from the local HIV community. Among others, Mick received the Catholic Mass Media Awards in 2006 for Best Investigative Journalism, and Art that Matters - Literature from Amnesty Int'l Philippines in 2020. Cross his path is the dare (guarantee: It won't be boring).


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