Capturing younger cohorts through surveillance systems: Philippines. Genesis May Samonte, MD. 3 September 2012 Expert Group Meeting Bangkok, Thailand

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1 Capturing younger cohorts through surveillance systems: Philippines Genesis May Samonte, MD 3 September 2012 Expert Group Meeting Bangkok, Thailand

2 National Surveillance Systems for STI & HIV DEPARTMENT OF HEALTH - PHILIPPINES

3 DEPARTMENT OF HEALTH - PHILIPPINES Objectives of the IHBSS To determine the prevalence of HIV and syphilis among the most at-risk populations and establish trend over time To determine behavioral factors associated with STI and HIV transmission and its effect on the HIV epidemic in the country To determine the outcome of STI and HIV intervention programs To provide strategic information to guide STI and HIV policies, programs and services

4 Process of including 15-17yo in the IHBSS DEPARTMENT OF HEALTH - PHILIPPINES

5 DEPARTMENT OF HEALTH - PHILIPPINES Age of first sex among MARPs, IHBSS 2007 * Age of first paid sex

6 Age first injected drugs among PWID, IHBSS 2007 DEPARTMENT OF HEALTH - PHILIPPINES

7 DEPARTMENT OF HEALTH - PHILIPPINES

8 Why do we need to collect data from adolescents? Consistent reports many teenagers are at-risk 2007 IHBSS data show high-risk young people are vulnerable to HIV or STI infection Data about high-risk adolescents sexual behavior is critically important for a targeted and effective response, raise awareness, tailor policies and programs. DEPARTMENT OF HEALTH - PHILIPPINES

9 DEPARTMENT OF HEALTH - PHILIPPINES Right of the Child and Best Interest of the Child Children should only participate in research on HIV if 1 : The study contributes to effective prevention, care, treatment and impact reduction for children. Children do not serve as research subjects until an intervention has already been thoroughly tested on adults. Consent of the child is sought and consent is based on full disclosure of the risks and benefits of research to the child. 1 The Convention on the Rights of the Child. General comment No. 3 (2003) HIV/AIDS and the rights of the child. Committee on the Rights of the Child, Thirty-second session, January 2003, United Nations New York, 17 March 2003.

10 Principles of enrolling minors The best interest of the adolescent is paramount. Adolescents who meet the eligibility criteria who are able to understand the risks and benefits of participating in the surveillance can do so without parental consent. Adolescents who lack the capacity to understand should not participate since participation with parental/guardian consent is not considered in their best interest. Adolescents requiring protection should be referred to appropriate agencies, if they agree. DEPARTMENT OF HEALTH - PHILIPPINES

11 Condition 1: Adolescents capacity to understand risks and benefits of participation Minor is able to repeat 4 key items of consent in participating in IHBSS: Participation is voluntary Information is confidential (no one will know about what you tell me) Participation involves interview and blood drawing with testing Benefit: Participation will help improve services for you (the adolescent) DEPARTMENT OF HEALTH - PHILIPPINES

12 DEPARTMENT OF HEALTH - PHILIPPINES Condition 2: Approval of ethics review The CWC HIV Committee chaired by DoH and other member agencies* have approved the inclusion of minors in the IHBSS and provided recommendations on the details the ethical issues regarding children. *DSWD, DILG, civil society such as Lunduyan, Remedios, PAFPI, Babae Plus, Precious Jewels, among others, and UNICEF

13 Condition 3: Availability, through referral, to psychological & social support services Surveillance Team Leader s responsibility to help adolescent access social or other protection services as needed. Final decision on whether or not the minor will be referred is up to the minor himself/herself. Education on HIV prevention and access to key social services should be provided if needed. DEPARTMENT OF HEALTH - PHILIPPINES

14 DEPARTMENT OF HEALTH - PHILIPPINES Philippine Integrated HIV Behavioral and Serologic Surveillance

15 2011 IHBSS Sampling Design Group SHC Registered Establishment- based Female Sex Workers (RFSW) Freelance FSW (FFSW) Behavioral Systematic Sampling: at Social Hygiene Clinic or at Entertainment Establishments Time Location Sampling Males having Sex w/ Males (MSM) Time Location Sampling People Who Inject Drugs (PWID) Respondent Driven Sampling Occupational Cohort of Men who are Clients of FSW (OCM) Purposive sampling DEPARTMENT OF HEALTH - PHILIPPINES

16 DEPARTMENT OF HEALTH - PHILIPPINES 2011 IHBSS Surveillance Sites Population Group Number of Sites RFSW 17 FFSW 18 MSM 18 PWID 4 OCM 6

17 2011 IHBSS Inclusion Criteria DEPARTMENT OF HEALTH - PHILIPPINES

18 IHBSS Results: FSW years of age among the FSW sampled years of age among the 15 to 24yo FSW 62% 58% 6% 6% All correct among UNGASS knowledge questions Ever tested for HIV Number of paying partners in a month (15-17 years old) Brings a condom Accessed Social Hygiene Clinic in past month 18% (15-17yo) 31% (18yo+) 5% (15-17yo) 24% (18yo+) Mean: 7/ month 10% (15-17yo) 21% (18yo+) 27% (15-17yo) 58% (18yo+) 20% (15-17yo) 39% (18yo+) 11% (15-17yo) 39% (18yo+) Mean: 11/month 14% (15-17yo) 24% (18yo+) 31% (15-17yo) 73% (18yo+)

19 IHBSS Results: MSM years of age among the MSM sampled 65% 61% years of age among the 15 to 24yo MSM 21% 21% All correct among UNGASS knowledge questions 24% (15-17yo) 36% (18yo+) 31% (15-17yo) 43% (18yo+) Ever tested for HIV 0.5% (15-17yo) 10% (18yo+) 4% (15-17yo) 16% (18yo+) Anal Sex without a condom in the past 12 months 58% (15-17yo) 53% (18yo+) 76% (15-17yo) 63% (18yo+)

20 Anal sex position and age-group, IHBSS 2011 DEPARTMENT OF HEALTH - PHILIPPINES

21 Percentage who buy their own condoms by age-group, IHBSS 2011 DEPARTMENT OF HEALTH - PHILIPPINES

IHBSS Results: PWID 2009 2011 15-24 years of age among the PWID sampled 55% 56% Percentage of 15-17 year olds among the 15 to 24yo PWID 12% 9% All correct among UNGASS

22 IHBSS Results: PWID years of age among the PWID sampled 55% 56% Percentage of year olds among the 15 to 24yo PWID 12% 9% All correct among UNGASS knowledge questions 24% (15-17yo) 46% (18yo+) 31% (15-17yo) 50% (18yo+) Injecting frequency (15-17 years old) Mean: 0.77/day Mean: 1.7/day Last injection shared (15-17 years old) 66% 59%

IHBSS Results: PWID 2009 2011 Used a condom during last sex (15-17 years old) 31% 14% Accepts payment for sex (15-17 years old) 52% 26%

23 IHBSS Results: PWID Used a condom during last sex (15-17 years old) 31% 14% Accepts payment for sex (15-17 years old) 52% 26% Used condom with last paying sex partner (15-17 years old) 21% 24% Ever tested for HIV None (15-17yo) 3% (18yo+) 6% (15-17yo) 12% (18yo+)

24 Age first injected drugs among PWID, IHBSS 2007 vs 2011 DEPARTMENT OF HEALTH - PHILIPPINES

25 DEPARTMENT OF HEALTH - PHILIPPINES 2011 IHBSS HIV Prevalence 15 to 17yo 18yo & older 15 to 24yo RFSW 0% 0.12% 0.11% FFSW 0% 0.28% 0.37% MSM 0% 1.93% 1.46% PWID 4 sites 6.15% 13.96% 9.50% PWID Cebu 50.0% 53.02% 50.0% PWID Mandaue 0% 4.01% 2.54%

26 Challenges encountered during IHBSS Some advocacy groups were against testing of minors and threatened surveillance teams Not enough social workers trained on HIV; referral system for minors was not clear in some areas IHBSS hours were not ideal Sampling Methods -- RDS: seed who is a minor is important TLS: depends on mapping Proportion of minors in total sample was too small to draw conclusions or generalizations DEPARTMENT OF HEALTH - PHILIPPINES

27 DEPARTMENT OF HEALTH - PHILIPPINES Other Results of the 2011 IHBSS Dept of Social Welfare & Development now has national policy and budget for HIV intervention; trained all their regional social workers on HIV Clearer referral arrangements for minors: DOH, DSWD, local govt, PLHIV community & civil society Strengthened HIV prevention programs for youth More social workers agree to act as the consenting guardians to minors who want to get tested for HIV More young people are aware about HIV & accessing voluntary HIV counseling and testing

28 DEPARTMENT OF HEALTH - PHILIPPINES

29 Newly diagnosed HIV cases in the Philippines: 17 years & younger DEPARTMENT OF HEALTH - PHILIPPINES

30 DEPARTMENT OF HEALTH - PHILIPPINES Things we are still thinking about: Program concerns: Still many program gaps but with data, programs can be more targeted Knowledge and HIV testing is increasing but condom use is still low. Age of first sex & drug use is still the same. Do we need to target even younger people? How do we address youth with multiple risks? Methodology: TLS seems to work for MSM but not too much for FSW. Maybe because sex work is a crime. Should we have more than one RDS seed who <18yo? Should the Philippines have a surveillance specifically for minors?

31 National HIV & STI Surveillance and Strategic Information Unit (NHSSS) National Epidemiology Center, Department of Health 2 nd Floor, Bldg. 19, San Lazaro Compound, Sta. Cruz, Manila 1003, Philippines HIVepicenter@gmail.com (+63)(02) (+63)(02) loc 2952 DEPARTMENT OF HEALTH - PHILIPPINES

HIV and AIDS in Bangladesh

HIV and AIDS in Bangladesh BACKGROUND The first case of HIV/AIDS in Bangladesh was detected in 1989. Since then 1495 cases of HIV/AIDS have been reported (as of December 2008). However UNAIDS estimates