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Uno: Making every moment count

When Uno tested HIV-positive, he found it “really heartbreaking to have your dreams shatter in front of you and knowing that you only have yourself to blame.” But he also learned some of life’s lessons when he tested positive. “The best lesson that HIV taught me is that life is indeed short. So I try to make every moment count from now on.”

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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.

It was in September 2012 when Uno first had an HIV-related symptom.  “Being an emergency room nurse, I am aware of several medical conditions… how it is acquired and all. (So in 2012) I was so surprised to have gotten boils (pigsa) on my buttocks. There were only two possible reasons for having it. First, poor hygiene; and second, (a compromised) immune system. I was pretty sure it was not because of my hygiene,” Uno said.

Although he is a medical professional, “back then, practicing safe sex was something ‘unessential’ for me. I had a strong feeling that I might have been infected with HIV, but I was so complacent that I ended up disregarding the idea of being positive.”

With his boils, instead of finding out if he was indeed infected by HIV, “what I did was just sought out medical treatment for my skin infection. After fully recovering from the skin infection I had, I completely dismissed the possibility of being HIV-positive that moment,” Uno recalled.

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But after just three months, “I had multiple boils in the same region, which I found very alarming. Together with the skin infection, I also realized how much weight I lost and how sickly I have become.”  So in  January this year, “I faced my fear of being HIV-positive. It was my own decision to get tested.”

Uno said he know how he got infected; but if asked from whom, “I was too promiscuous to identify who infected me,” he said.

After he tested positive, “my initial reaction was nothing… I did not feel anything. I felt disconnected from myself.”

Also after he tested positive, “the biggest challenge that I had to face was to take care of myself when I got severely ill. Most of my family members were in the US during that time I had pneumonia and boils. Although my younger siblings were around, I felt that it would be unfair for them to attend to my medical needs. So, I had to nurse myself to full recovery.”

Nowadays, though, “my support group consists of two of my siblings, two close friends from college, and a group of fellow HIV-positive individuals I met from a training program about self-empowerment. To this day, I still haven’t found the purpose of disclosing my status to the rest of my family, especially to my parents. As selfish as it may sound, I don’t think that my parents deserve to know my condition – my mom in particular who is battling with cancer for almost a decade now.”

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On disclosure, Uno believes that “telling someone that you’re HIV-positive is like letting that person have your Kryptonite. It’s in their power to protect you or harm you. And I try my best not to give much of my Kryptonite away.”

Uno was advised to take ARVs from the moment he got his first CD4 result. “I am now in my eighth month of ART. Aside from having periodic rashes, I have been feeling a lot healthier compared to before.”

If there is a “major drawback” for testing positive, Uno said it is “not being able to ‘fully’ practice my profession as a nurse here or abroad. I had to let go of my career as a nurse. One major reason why I decided to quit my job is having the fear of being discriminated. Sadly, even among medical professionals, being HIV-positive will lead to direct or indirect discrimination. It was really heartbreaking to have your dreams shatter in front of you and knowing that you only have yourself to blame.”

In hindsight, “to this day, I am still sorry for disappointing myself, but I am also slowly coming into terms with the fact that past is past. Although things got out of hand, I took full ownership of my situation by working out (the) things that I have a control of and letting go of things that I can not change.”

But Uno learned some of life’s lessons when he tested positive. “The best lesson that HIV taught me is that life is indeed short. So I try to make every moment count from now on,” Uno said. “I know that I am still a work in progress. Every day, I maintain a conscious effort to truly love myself. I am now a firm believer of the statement: ‘You can only love others when you love yourself’. And from that love I invest within me, I can love others. You only have one life, treasure it, because you are a gem. And that’s the lesson I can share to everyone.”

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POZ

New studies, WHO guidance clarify way forward for use of dolutegravir in women of childbearing age

Additional research from Botswana has found that the risk of NTDs is less than was signalled last year. To help clinicians and health ministries act on these findings, WHO issued updated recommendations on antiretroviral therapy and DTG use.

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The safety of the HIV treatment drug, dolutegravir (DTG), during pregnancy has been one of the most urgent questions in global health for the past year.

At the 22nd International AIDS Conference (AIDS 2018) last year, data from the Tsepamo study in Botswana suggested that the use of DTG in early pregnancy may be linked to neural tube defects (NTDs), serious birth defects of the brain and spine.

As a result, some countries have paused their plans to make DTG-based regimens their preferred first-line therapy and the World Health Organization (WHO) issued a note of caution about the use of DTG by women of childbearing age as part of its interim guidelines recommending DTG as the preferred first- and second-line antiretroviral therapy for people living with HIV.

At the 10th IAS Conference on HIV Science (IAS 2019), additional research from Botswana has found that the risk of NTDs is less than was signalled last year. To help clinicians and health ministries act on these findings, WHO issued updated recommendations on antiretroviral therapy and DTG use.

To inform these recommendations, a number of community and scientific forums were held to discuss the issue directly with women of reproductive age who have the least access to obtaining DTG. 

“Community engagement, including input from women living with HIV, has played a key role in updating these recommendations and will be critical to rolling them out,” Jacque Wambui, African Community Advisory Board (AFROCAB) member, Kenya, said.

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“Ultimately, what is most important is offering women the choice to make informed decisions,” Anton Pozniak, International AIDS Society President and IAS 2019 International Scientific Chair, said.

WHO updated these recommendations based on new evidence.

Botswana’s Tsepamo study analysed more than 119,000 deliveries from August 2014 to April 2019, including nearly 1,700 among women who were taking DTG-based therapy around conception. With more data, the researchers have found the risk in the prevalence of NTDs among women taking DTG is less than originally signalled. Specifically, NTDs occurred in three per 1,000 deliveries among women on DTG from conception – compared with one per 1,000 deliveries among women taking other ARV regimens.

A second analysis from Botswana analysed health facilities that were not included in the Tsepamo study. Examining data from 22 facilities from October 2018 to March 2019, researchers confirmed one case of NTDs in pregnancies of 152 mothers who had been taking DTG-based therapy at conception. By comparison, two cases of NTDs occurred among pregnancies of more than 2,300 HIV-negative mothers.

Meanwhile, a surveillance-based analysis from Brazil included 1,468 women who became pregnant while taking antiretroviral therapy – 382 of whom were taking DTG at conception. In this case, no cases of NTDs were seen. This evidence backs up the overall conclusion that even if DTG-based therapy is associated with an elevated risk of NTDs, the risk remains quite low.

To help put these findings in context and to provide urgently needed guidance, WHO issued updated recommendations on antiretroviral treatment. These guidelines reconfirm the recommendation to use DTG-containing regimens as the preferred option for first-line and second-line antiretroviral treatment (ART) across all populations.

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The guidelines development group also emphasized the need for ongoing monitoring of the risk of NTDs and the importance of supporting women’s autonomy in decision making and informed choice. 

“There is still a risk that we and countries need to monitor closely, but at this point, dolutegravir should be accessible for women of childbearing age due to the overwhelming benefits it offers,” Meg Doherty, Coordinator of Treatment and Care in the Department of HIV/Hepatitis and STIs at WHO, said. “What treatment options to pursue is a decision that a woman should make in consultation with her healthcare provider.”

Ambassador Deborah L. Birx, U.S. Global AIDS Coordinator and U.S Special Representative for Global Health Diplomacy, commented that the President’s Emergency Plan for AIDS Relief (PEPFAR) was committed to supporting countries in their continued transition to DTG. “DTG offers many benefits, including that it is better tolerated by the patient, leads to improved outcomes, such as faster viral suppression, and often costs less,” she said. “It is clear that transitioning to DTG will accelerate our progress toward controlling the HIV epidemic.”

Earlier this month, Pozniak, Doherty and Wambui alongside several other coauthors, released a commentary entitled “Optimizing responses to drug safety signals in pregnancy: the example of dolutegravir and neural tube defects.” Published in the Journal of the International AIDS Society (JIAS), the piece provided additional context before the new data shared at IAS 2019 became available.

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Implementing rules and regulations of new HIV Law signed

The new law provides for the lowering of age of consent from 18 to 15 years old. This law also ensures the development of program for treatment, care and support for persons confined in closed-setting institutions. It likewise provides stiffer penalties for breaching confidentiality with regards to ones’ HIV status.

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The Implementing rules and regulations (IRR) of Republic Act 11166, otherwise known as the Philippine HIV and AIDS Policy Act, which eyes to address the growing HIV epidemic in the country, has been signed. The new law repealed RA 8504.

“We are confident that the new law will forge a stronger alliance among government, private sector, civil society organizations, faith-based organizations, media and all stakeholders in order for us to overcome the HIV epidemic,” Health Secretary Francisco T. Duque III said.

It should be noted that in 2008, an average of one infection per day was recorded. This has now ballooned to 36 new infections per day as of April 2019.

“We should act now as fast as we can since 29% (240/840) of all new confirmed HIV cases last April 2019 affect our youth aged 15-24 years old,” Duque said.

In order to address the worsening situation, the new law provides for the lowering of age of consent from 18 to 15 years old. The law specifically provides for intervention through the matured minor doctrine and the provision of proxy consent for children below 15 years old.

The education component of the program was also strengthened by mandating learning institutions to focus not only on the right information on HIV and AIDS but also in human rights principles to reduce stigma and discrimination. HIV education will also cover Indigenous Peoples (IP) communities and communities in the geographically isolated and disadvantaged areas (GIDA).

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A “Comprehensive Intervention” shall be provided to the key affected population which includes males having sex with males (MSM), sex workers, people who inject drugs (PWID), transgender people, and overseas Filipino workers (OFW). The law also provides care and support to all people living with HIV (PLHIV), their affected families and especially the orphaned children.

This law also ensures the development of program for treatment, care and support for persons confined in jails, rehabilitation centers and other closed-setting institutions. It likewise provides stiffer penalties for breaching confidentiality with regards to ones’ HIV status, and much higher liability for those who have access to this information.

No PLHIV shall be denied or deprived of private health insurance under a Health Maintenance Organization (HMO) and private life insurance coverage under a life insurance company on the basis of a person’s HIV status.

“The active involvement of all HIV and AIDS stakeholders will be the key element for the success in the implementation of this new law in achieving the overall health of the PLHIV Communities. This law ensures the effective implementation of our country response to HIV and AIDS through the Philippine National AIDS Council,” Duque concluded.

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Two new algorithms can identify patients at risk of HIV

The final risk prediction model included such variables as sex, race, living in a neighborhood with high HIV incidence, use of medications for erectile dysfunction, and sexually-transmitted infection (STI) testing and positivity.

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Two new studies developed algorithms that can identify patients who are at risk of acquiring HIV and may benefit from preventive care. Both studies appear in the July issue of The Lancet HIV.

Preexposure prophylaxis (PrEP) is an antiretroviral pill that is over 90% effective in preventing HIV acquisition when taken as prescribed. PrEP was recently given a Grade A recommendation from the U.S. Preventive Services Task Force but is vastly underutilized. There are nearly 40,000 new HIV infections annually in the United States, yet the Centers for Disease Control and Prevention estimates that only 7% of the 1.1 million individuals at substantial risk for HIV infection used the antiretroviral pill in 2016.

One barrier to use is the difficulty for providers in identifying patients who are at high risk of HIV acquisition. Providers often have limited time, may have limited knowledge about PrEP, and may lack training in how to talk to patients about sex or substance use. Risk prediction tools, a form of electronic clinical decision support using the data in patients’ electronic health records (EHRs), are often used in other areas of medicine. Researchers from both studies, one using a patient population in California and the other in Massachusetts, built HIV risk prediction models that could be used in EHRs as automated screening tools for PrEP.

The two studies looked back at the medical records of millions of patients who were HIV-uninfected and had not yet used PrEP. Researchers extracted demographic and clinical data from these patients’ EHRs on numerous potential predictors of HIV risk. A machine-learning algorithm automatically selected important HIV risk-related variables for the final models.

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In the California-based study, which used medical record data of 3.7 million patients at Kaiser Permanente Northern California, the final risk prediction model included such variables as sex, race, living in a neighborhood with high HIV incidence, use of medications for erectile dysfunction, and sexually-transmitted infection (STI) testing and positivity. The model flagged 2% of the general patient population as potential PrEP candidates and identified 46% of male HIV cases, but none among females.

“Although risk prediction tools are imperfect and cannot replace the clinical judgement of skilled providers, our algorithms can help prompt discussions about PrEP with the patients who are most likely to benefit from it,” said Julia Marcus, PhD, MPH, lead author of the California-based study and Assistant Professor of Population Medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School.

The Massachusetts-based study used a patient population of 1.1 million patients at Atrius Health as well as the population of Fenway Health, an independent community health center in Boston specializing in sexual health care, to test performance in a new setting with higher rates of new HIV infection. The final risk prediction model included sex, race, primary language, as well as diagnoses, tests, or prescriptions for STIs. The model flagged 1.8% of the general patient population at Atrius Health and 15.3% of the population at Fenway Health as potential PrEP candidates. The model also identified 37.5% of new HIV cases at Atrius Health and 46.3% at Fenway Health.

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According to Douglas Krakower, MD, lead author of the Massachusetts-based study and Assistant Professor at Beth Israel Deaconess Medical Center, the Harvard Pilgrim Health Care Institute, and Harvard Medical School, “integrating these prediction models into primary care with routine, comprehensive HIV risk assessments by clinicians could play an important role in increasing the prescription of PrEP and preventing new HIV infections.”

Jonathan Volk, MD, senior author of the California-based study and an infectious disease physician at Kaiser Permanente San Francisco Medical Center added that “a recent publication by the U.S. Preventive Services Task Force in JAMA cites the lack of effective prediction models as a major gap in research that is critical to improving PrEP delivery. Our model helps fill that gap.”

The California study, titled “Use of electronic health record data and machine learning to identify potential candidates for HIV preexposure prophylaxis: a modelling study”, is co-authored by investigators from: Harvard Pilgrim Health Care Institute, Kaiser Permanente Division of Research, Beth Israel Deaconess Medical Center, and Kaiser Permanente San Francisco Medical Center. The project was supported by the Kaiser Permanente Northern California Community Benefit Research Program, the National Institute of Allergy and Infectious Diseases, and the National Institute of Mental Health.

The Massachusetts study, titled “Development and validation of an automated HIV prediction algorithm to identify candidates for preexposure prophylaxis”, is co-authored by investigators from: Beth Israel Deaconess Medical Center, Harvard Pilgrim Health Care Institute, Massachusetts Department of Public Health, Boston Medical Center, Atrius Health, New England Quality Care Alliance, Brown University, The Fenway Institute, and Brigham and Women’s Hospital. The project was supported by the National Institute of Mental Health, Harvard University Center for AIDS Research, Providence/Boston Center for AIDS Research, Rhode Island IDeA-CTR, and the US Centers for Disease Control and Prevention through the STD Surveillance Network.

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Greater prevalence of anal cancer precursors for women living with HIV than prior reports

The results call for new strategies to be developed for wider screening of women living with HIV, who have disproportionally higher rates of anal cancer compared to the general population of women.

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The prevalence of anal high-grade squamous intraepithelial lesions (HSIL), which precede anal cancer, is much higher in women living with HIV than previously reported, a multi-site, national study involving hundreds of patients has found.

Conducted by researchers from the AIDS Malignancy Consortium, a National Cancer Institute-supported clinical trials group, the results call for new strategies to be developed for wider screening of women living with HIV, who have disproportionally higher rates of anal cancer compared to the general population of women. The study appears in Clinical Infectious Diseases.

To determine the true prevalence of anal HSIL in women living with HIV in the United States, the researchers, for the first time, conducted a full anal evaluation including a high resolution anoscopy (an examination of the anus under magnification) with directed biopsy on all 256 female study participants, not just on those who had an abnormal screening test or triage. The prevalence of anal HSIL was 27 percent, substantially higher than previous study estimates, which ranged between four to nine percent.

“We believe most prior studies of anal HSIL prevalence in women living with HIV under-represented the true percentage because only individuals with abnormal anal cytology underwent high resolution anoscopy in past studies, compared to all the participants in this new study,” said Dr. Elizabeth Chiao, the co-author and principal investigator of the study. Dr. Chiao is a professor of medicine in the section of infectious diseases at Baylor College of Medicine and with the Houston VA Center for Innovations in Quality, Effectiveness and Safety.

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The study was conducted at 12 academic medical centers across the United States, with the participants recruited between 2014 and 2016. The mean age of participants was 49.4 years, 64 percent were non-Hispanic black, and 67 percent were former or current smokers.

“The high prevalence of anal cancer precursors and invasive anal cancer among women living with HIV calls for greater screening in this population,” said lead author Elizabeth Stier, MD, of Boston Medical Center, who is also an associate professor of obstetrics and gynecology at Boston University School of Medicine. “Because optimal screening strategies are still not yet known, prevention of anal cancer among this population should focus on identifying cost-effective strategies for the detection and management of anal cancer precursors.”

Screening women living with HIV for anal cancer has been recommended by national organizations, including the American Cancer Society, the Infectious Diseases Society of America, and the American Society of Colon and Rectal Surgeons.

The study was supported by the National Cancer Institute at the National Institutes of Health.

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POZ

54% of April’s HIV cases from 25-34 age group; and 29% are 15-24 years old at time of testing

Sexual contact remained as the predominant mode of transmission (98%, 819). Among the newly diagnosed, 57% (475) reported transmission through male to male sex, 24% (203) through sex with both males and females, and 17% (141) were through male to female sex.

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Younger people continue to be the most affected by HIV in the Philippines, with the median age of those newly infected in April 2019 27 years old (age range: 2-73 years old). More than half of the new HIV cases (52%, 434) were 25-34 years old, and 29% (240) were 15-24 years old at the time of testing.

In April, there were 38 newly diagnosed adolescents 10-19 years old at the time of diagnosis. Further, two cases were 17 years old and 36 cases were 18-19 years old. Almost all (95%) were infected through sexual contact (six male-female sex, 19 male-male sex, and 11 had sex with both males and females), one was infected through sharing of needles and one had no data on mode of transmission.

There were three diagnosed cases less than 10 years old and all were infected through vertical transmission (formerly, mother-to-child transmission).

This is according to the latest report from the HIV/AIDS & ART Registry of the Philippines (HARP), which cited that 840 Filipinos were newly infected for the fourth month of the year. Ninety-four percent (789) of the newly diagnosed were male.

Almost a third (32%, 271) were from the National Capital Region (NCR). Region 4A (16%, 137), Region 3 (11%, 92), Region 7 (8%, 65), and Region 6 (7%, 55) comprised the top five regions with the most number of newly diagnosed cases for the month, together accounting for 74% of the total.

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Sexual contact remained as the predominant mode of transmission (98%, 819). Among the newly diagnosed, 57% (475) reported transmission through male to male sex, 24% (203) through sex with both males and females, and 17% (141) were through male to female sex.

Still in April 2019, 14% (114) of the newly diagnosed engaged in transactional sex. Ninety-eight percent (112) were male and aged from 17 to 62 years old (median: 28 years). Forty-six percent (52) of the males reported paying for sex only, 38% (42) reported accepting payment for sex only and 16% (18) engaged in both. Also, among the two female cases who engaged in transactional sex, one was reported to have accepted payment for sex and one had engaged in both.

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.

Other modes of transmission were sharing of infected needles (1%, 5) and vertical transmission, with <1%, 3). There were 13 cases that had no data on mode of transmission.

Among the newly diagnosed females in April, four were pregnant at the time of diagnosis. Two cases were from Region 4A and one case each from Regions 1 & 10.

Reporting of pregnancy status at the time of testing was included in the HARP from the year 2011.

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In April 2019, there were 752 patients who were initiated on ART. The median CD4 of these patients upon enrollment was 204 cells/mm3. As of end-April 2019, a total of 37,091 PLHIVs were already on ART.

There were 189 reported deaths due to any cause among PLHIVs. Ninety-five percent (179) were males. Thirty-one (16%) cases were 15-24 years old at the time of death, 97 (51%) were 25-34 years old, 52 (28%) were 35-49 years and nine (5%) were 50 years and older. Ninety-five percent of the cases were reported to have acquired the infection through sexual contact: 31 through male-female sex, 92 through male-male sex, and 57 through males who have sex with both males and females. Four (2%) were infected through sharing of needles and one (1%) was through mother-to-child transmission. There were four (2%) reported deaths that had no data on mode of transmission.

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POZ

HMOs ordered to provide medical coverage to people with HIV… with limitations

HMOs are expected to provide coverage to PLHIVs under the following conditions: he/she is undergoing proper medical treatment; he/she has a favorable risk profile; and the results of the medical examinations required by the HMO are within normal limits.

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The Insurance Commission (IC) has ordered health maintenance organizations (HMOs) to provide medical coverage to people living with HIV (PLHIVs), as contained in Circular Letter No. 2019-30, issued by Insurance Commissioner Dennis B. Funa on June 21.

The document is in line with Republic Act (RA) No. 11166, or the Philippine HIV and AIDS Policy Act, signed by President Rodrigo Duterte in December 2018.

Under the circular, the IC will implement and develop policies that will ensure compliance with Section 42 of RA 11166, which states that no person/s living with HIV “shall be denied or deprived of private health insurance under an HMO on the basis of a person’s HIV status.”

Section 49 of the law also prohibits “denial of health services, or being charged with a higher fee, on the basis of actual, perceived or suspected HIV status.”

HMOs are expected to provide coverage to PLHIVs under the following conditions: he/she is undergoing proper medical treatment; he/she has a favorable risk profile; and the results of the medical examinations required by the HMO are within normal limits.

But the IC circular isn’t completely PLHIV-friendly.

Notably, HMO applicants may still be required to undergo HIV testing “based on parameters such as, but not limited to, age, total amount at risk, and occupation/lifestyle; provided that the applicant voluntarily consents to such testing pursuant to Article IV of RA 11166,” the IC said. This “HIV testing shall be performed by health facilities recognized by the Department of Health and have the capacity to provide services on HIV testing and counseling.”

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Also notably, the insurance regulator allows HMOs to temporarily suspend or decline the application of PLHIVs who has other medical conditions or other risk factors which would have also resulted in the suspension or denial of the application even if not HIV positive. These include kidney, liver or cardiovascular diseases, hepatitis B or C, pulmonary tuberculosis, signs of infections brought on by a weakened immune system, smoking, and injection of illegal drugs.

HMOs are also allowed to set limits of acceptance for PLHIVs depending on their age, payment terms or amount of coverage, upon approval of the IC. And – seemingly negating itself – HMOs may not decline an application solely based on the HIV status of the applicant, but they can still choose to deny coverage of PLHIVs.

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