The Philippines second largest city, Cebu, faces an “explosive HIV epidemic among people who inject drugs and men who have unprotected sex with men,” according to a briefing paper that says the rapid spread in infections is due to the sharing of contaminated needles and syringes. The document was produced by the World Health Organization, the Philippine Department of Health and Cebu health authorities.

Growing risk factors

However, Philippine Sen. Vicente Sotto III, the Senate Floor Leader and ironically the chairman of former President Gloria Macapagal Arroyo's Dangerous Drugs Board, appears almost certain to scuttle a study on needle exchange, arguing in the Senate that giving needles to intravenous drug users “is like giving murderers clean knives in place of their rusty ones so that they can kill them without infecting them with tetanus.”

Sotto, a onetime slapstick movie comedian who frequently parodied gay men, appears to take his stance from either bias or pure ignorance – or possibly cynical political calculation, since his objections have increased his popularity, according to a statement from the Philippine office of Human Rights Watch. The latter seems most likely, since he attended a high-level study commission in Vienna on narcotics in 2009, long after needle exchange programs were found to be successful in the Netherlands in the 1980s and presumably would have been informed of their effectiveness.

The Philippines has been largely insulated from the flow of heroin. But, according to a study for the United Nations Development Program, the use and popularity of amphetamine stimulants such as methamphetamine is growing, including via injection.

“Assessments show that men having sex with men who use methamphetamines may increase their sexual risk factors [for example, they may use condoms less often, have more sex partners, and may engage in practices that elevate their risk for HIV infection, such as unprotected receptive anal sex] and perhaps their HIV-related drug-use risk factors, for example, injecting methamphetamine intravenously,” according to the UNDP report

China, Cambodia, Malaysia, Indonesia, India, Vietnam and Thailand have all implemented needle and syringe exchange programs, China first in 1999. Overall millions of needles and syringes have been exchanged in thousands of sites across the region. A 2013 analysis printed in the International Journal of Epidemiology found that needle exchange programs reduced the risk of HIV infection by a third. The UN believes Asia’s epidemic peaked in the mid-1990s, and annual HIV incidence has subsequently declined by more than half, with the epidemic remaining stable since 2000. Thus the refusal of Sotto to allow the government to opt for a proven regime seems especially unfortunate.

Heads in the sand

Tragically, according to Human Rights Watch, Sotto’s Senate colleagues seem to agree with him. The Senate Committee on Public Order and Dangerous Drugs, chaired by possible Presidential candidate Grace Poe, has told the Department of Health to suspend the distribution of syringes to drug users. The study has been funded by the World Bank and supported by Filipino NGOs.

“There is compelling evidence that reducing the sharing of infected needles by providing clean needles helps to combat AIDS,” Human Rights Watch said. “Access to clean syringes also helps prevent overdose and provide a gateway for drug treatment programs, Human Rights Watch said in a 2013 report, “In Harm’s Way,” which examined drug users and HIV in the US city of New Orleans. Providing clean needles, experts and advocates agree, would be a key step in the right direction.”

In the meantime, according to the combined World Health Organization–Philippine health study, a human tragedy is unfolding in Cebu that is certain to run up public health costs dramatically as drug users contract HIV and ultimately AIDS.

“In 2008 HIV transmission was primarily due to sexual contact [90 percent], but by 2012 it was injecting drug use [77 percent]," according to the study. "The 2011 biological and behavioral surveillance in Cebu City reported HIV prevalence among [intravenous drug users] to be 54 percent, with Hepatitis C prevalence reaching 94 percent."

The same study found 15 percent of freelance female sex workers had injected drugs and among male injectors 24 percent reported same-sex behaviors. There are an estimated 6,000 intravenous drug users in metro Cebu, with 2,000 to 2500 in Cebu City, of which the majority share their injecting equipment, the report found. “Many are sexually active, resulting in spread of HIV to their non-injecting wives/partners and then possibly to their babies. The current public health crisis requires an urgent and well-coordinated response.”

The fear is that “the trend of intravenous drug users rapidly transmitting HIV will spread to other cities," said the 2014 briefing paper. Intravenous drug use has overtaken sexual contact as Cebu City’s main mode of HIV transmission, the report said.

“A suspension of the study, which now seems likely, would be a step backwards for the Philippines,” according to Human Rights Watch. “Adopting needle exchanges is not only cost-effective and good for the health outcomes of people who use drugs, it is also good for their families and the communities in which they live.”