The TB-HIV syndemic

HIV is rising dangerously in the Philippines. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that, with 35 new cases being diagnosed every day, there will be 200,000 Filipinos infected with the virus by 2025. Even more alarmingly, there is a steady increase in the younger age range of 15-24 years old; in June 2019 alone, there were 54 newly diagnosed cases among 10-19-year-olds.

Meanwhile, tuberculosis (TB)—a disease that has been around for centuries—continues to plague the country; the Department of Health (DOH) estimates that it claims the lives of 60 to 70 Filipinos a day. And although TB prevalence is declining, it is not declining fast enough. Last year, an estimated 591,000 Filipinos fell ill from TB, accounting for 6 percent of the 10 million global total, surpassing figures in countries like Nigeria and Bangladesh.

These two diseases are not unrelated to each other. Because HIV is a state of lowered immunity, many people living with HIV (PLHIV) are prone to TB infections. Already difficult to treat to begin with, TB is especially complicated on top of HIV, and it ranks as the leading cause of deaths among PLHIV. Moreover, PLHIV are also more likely to die during treatment for multidrug resistant tuberculosis.

The existence of the TB-HIV “syndemic” (defined by the medical anthropologist Merrill Singer as the synergistic interaction of various epidemics as well as social factors like poverty) is yet another reason why we should redouble our efforts to address them.

Thankfully, we already know what to do to address TB cases; Health Secretary Francisco Duque III himself outlined a three-fold strategy: “high-level commitment, massive screening, testing and treatment, and mandatory notifications by the private sector.”

We also know that we need similar measures for HIV, above all increasing access to screening, testing and treatment. Fortunately, access to HIV testing has now expanded through the DOH’s recent policy of allowing screening to be done by trained medical and paramedical staff. Republic Act No. 11166 also lowered the age of HIV testing without need for parental consent from age 18 to 15.

However, challenges remain, not least of which are the stigma and discrimination that prevent people, particularly the youth, from consulting at all.

The lack of both TB and HIV medications continues to be reported across regions, and the limited availability of treatment for other HIV coinfections (including TB) remains a burden for many PLHIV, as these are usually paid out of pocket. The availability of the HIV pre-exposure prophylaxis or PrEP is now part of the HIV arsenal, but has yet to reach most of its intended users.

The level of knowledge, moreover, remains low for both diseases, which doubtless contributes to more risky behavior. To date, the use of condoms among those who engage in anal sex is only 50 percent.

Finally, the social determinants of TB and HIV are both poorly emphasized in many action plans. TB, after all, does not exist in a vacuum, and as Singer’s definition of “syndemic” suggests, we need to look at contributory factors including malnutrition, substandard housing and poor living conditions.

Still, there are innovative solutions from civil society groups and government agencies that offer hope. For instance, a number of local government units (e.g., Manila and Quezon City) have initiated sun-down clinics—public clinics that are open after the usual office hours to cater to those who can access the clinics only at end of day. Taguig, for its part, is trying out an on-call mobile testing service, where public health practitioners on motorbikes can go to a person’s location when they receive a request for HIV testing. The DOH and local government units have also tested the potential of engaging private clinics in expanding access to HIV (and TB) bidirectional testing and treatment, with promising results.

But for all these efforts to succeed, they require the full support of our highest officials, who must recognize health as a right and a priority—and reflect such recognition in our health budget. Ending the TB-HIV syndemic—and saving the lives of thousands of Filipinos—will depend on their action and leadership.

Mary Ann Evangelista, MD, is a public health practitioner and program manager at Hivos SEA, a nonprofit organization, where she works on improving access to HIV and TB care. Gideon Lasco, MD, Ph.D., is an Inquirer columnist, medical anthropologist and advocate of equity in health.