Ilya Abellanosa Tac-an, MD, PHSAE City Health Department Cebu City, Philippines

Disclaimer: The views expressed in this paper/presentation do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

I. Cebu City Profile

2nd largest city with fastest growing economy in the Philippines Total Popn: 866,171 (2010 census) 80 barangays 50 urban barangays (villages) 30 mountain barangays (villages) 84 Barangay Health Stations Estimated no. of PWID: 2,000-2,500 (2013)

II. HIV/AIDS Cases in Cebu City by Year

Cebu City HIV/AIDS Registry 1989- Sept 2013 N= 868
Number
280 260 240 220 200 180 160 140 120 100 80 60 40 20 0
AIDS

Fast and Furious

AIDS Asymptomatics

Low and Slow Prevalence

Hidden and Growing

89

90 1 1

91 1 0

92 1 2

93 3 1

94 1 1

95 4 1

96 3 2

97 4 4

98 3 2

99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 2 2 1 3 2 1 1 0 3 4 2 2 3 2 2 5 1 7 3 10 176 141 183 263 1 1 3 5 1

Asymptomatics 3 0

Year **Age Range = 15-79 yrs. old 39% = 15-24 years old

HIV Prevalence per Group per Round

Cebu City Integrated HIV Surveillance, 1995 - 2013

Percent
60 55 50 45 40 35 30 25 20 15 10 5 0

MSM

IDU

'95 MSM 0 IDU 0

96 0 0.6

97 0.6 0

98 0 0

99 0 0

'00 0 0

'01 0 0

'02 0 0

'03 0.3 0

'04 0 0

'05 0 0.8

'07 0 0.4

'09 1 0.5

'11 4.7 53.3

13 7.7 48

Year

FREQUENCY Injects more than 1x per day (OR 8.02 p=0.000) DURATION Duration of injecting drugs > 1yr (OR 3.19 p=0.000)

PLACE Last injection in Kamagayan shooting gallery (OR 5.31 p=0.000)

NEEDLE SOURCE Needle source last injection: service needles (OR 2.42 p=0.000)

Prevention Coverage: IHBSS, 2011

PWID 35%

Key Affected Populations

MSM

23%

MSW

79%

FSW

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Percentage

IV. Current Situation

A concentrated HIV epidemic among
- injecting drug users (2013) - men having sex with men (2013) - free-lance sex workers (2011) - 48% - 7.7% - 5.4%

High prevalence of Hepatitis C among PWID: 94%

Sexual partners of PWID are at higher risk

- 26 HIV+ women became pregnant from 2010-2013

- PWID - Wife/Sex partner of PWID - Not drug related

: 10 : 14 : 2

Only one Social Hygiene Clinic

Over-burdening the Health System

Chain of HIV Spread

Female Partner of MSM Male IDU

Female Partner of Male IDU Female IDU

Baby

Baby

Baby

MSM
Male Client of MSW Male Sex Worker Female Partner of Male Sex Worker

Baby Male Client of FSW

Female Partner of Male Clients

Baby

Baby

Freelance FSW

Registered FSW

Baby

V. Current Local Response (Since 2010)

A. Policy advocacy:
- Presented situation to city/village councils - Submitted the proposed harm reduction program and supporting policies to the City Council - Consultative meetings with shooting gallery owners/pimps/operators

B. Facility-Based Needle and Syringe Program

C. Multi-Sectoral Collaboration
Consultative meetings with selected government agencies and non-government organizations:
- Local AIDS Council - Phil. National Police - Dept. of Health - Phil Drug Enforcement Agency - Dept. of Interior & Local Govt - Selected NGO

*Agreed to come up with local guidelines for N/S distribution

National Response (Since 2011)

Policy Advocacy National level
Consultations with the Dangerous Drugs Board (DDB), Phil.

Drug Enforcement Agency (PDEA), Philippine National Police (PNP), Dept. of Interior and Local Government (DILG), and the DOH in coming-up with appropriate and effective approaches to prevent the rapid spread of HIV among injecting drug users
Drafting of an Operational Research Proposal for a Needle and

Syringe Management Program to promote behavior change among injecting drug users
Formulation of a Comprehensive HIV and Drug Use Prevention

and Control Program

Ongoing Interventions for PWID

Community Outreach and Peer Education (GFATM) STI Diagnosis and Treatment (DOH and Local Government) HIV Counseling and Testing (facility-based and mobile) Facility-Based Needle and Syringe Program Prevention of Mother-to-Child Transmission HIV Treatment, Care and Support (Social Hygiene Clinic as satellite treatment hub) Capability Building for PEs and Health Providers Establishment of Networks and Linkages with other GOs, NGOs and CBOs

VI. Challenges & Inhibiting Factors

A. Dangerous Drugs Act/Policy on Needle Distribution

in the Community Section 12 of The Comprehensive Dangerous Drugs Act of 2002 penalizes persons carrying or having under his/her control any equipment or paraphernalia for injecting, ingesting, or introducing any dangerous drug into the body
B. Limited number of personnel for PWID interventions
B. Limited Number of PWID availing the facility-based N/S

program

With clarity on the need for policy change, community and local government stakeholders, together with the DOH and PNAC, continued with targeted advocacy

On September 12, 2013 The Dangerous Drug Board approved the Pilot Operations Research Proposal for Needle

and Syringe Management in Barangay Kamagayan in Cebu City, which will be supported
by the HIV Prevention in Big Cities Project.

VIII. Pilot Study/Operations Research (OR)

Expected Impact Decreased HIV transmission among PWID in Cebu City Desired Outcome Reduced high risk sexual and injecting behaviors among PWID

Key Interventions
Developing friendly services for PWID (e.g., drop-in center) in the big cities; 2. Increasing the demand and use of services by PWID, to help them reduce risky behaviors, through improved peer education and support; 3. Strengthening governance for development and implementation of evidence-based policies and interventions, at both national and local levels, by collecting strategic information (through appropriate studies) developing evidence-based policies and programs, and developing LGUs capacity to implement effective interventions at the local level.
1.

VII. Lessons Learned/Good Practices

Utilizing surveillance data for interventions

Local AIDS Council (CCMSAC) could take the lead in mobilizing local HIV/AIDS stakeholders and other agencies (PDEA/PNP, city/barangay officials) for a collaborative interventions
Importance of Harnessing Multi-Sectoral Partnerships WHO/GFATM-TFM/UNICEF Logistics
DOH/UNAIDS/USAID Technical support
CCMSAC/Local Stakeholders/IDUs and their network HRP LGU (city/barangay), other agencies (PDEA/PNP) policy

support, access to MARPs and their social networks

HACT/Cebu Plus ARV, CD4 count, care and support ADB/WB Big Cities Project

IX. Sustainability Plan

Amendment of the City Local Ordinance to incorporate
interventions for PWID and other Key populations

Institutionalization of hired Peer Educators Development of MOA with CHO, CBOs and village
council

Integration of HIV programs into the City-wide

Investment Plan for Health (CIPH)

Active forecasting of drugs and reagents for DOH

support

Infrastructure and equipment support to SHC and DIC

Thank you very much!