Policy breakthrough for a needle and syringe program for people who inject drugs in Cebu City, Philippines Dr Ethel Dano, WHO local consultant, Cebu, Philippines Dr Ilya An-Tac, Cebu City Health, Philippines Dr Gerard Balimac, Department of Health, Philippines Dr Zhao Pengfei, WHO Western Pacific Regional Office, Philippines

Outline 1.The HIV epidemic in the Philippines 2.Advocacy and technical assistance 3.Summary of lessons learned 4.The way forward

Every 2 hrs a Filipino becomes HIV infected… As of June 2013, Philippine HIV Registry – NEC/DOH new cases a day or 1 new case every 3 hours 13 new cases a day new cases in 3 days

Quick glance at HIV in the Philippines Population: 92.34M (NSO 2010) Projected number of people living with HIV (15-49) by 2014: 32,279 Reported cases since 1984: 16,516 HIV cases (15,009) AIDS cases (1,507) Reported AIDS deaths: 887 The first reported Filipino HIV case in the Philippines In 1984 is a heterosexual male OFW. HIV Data Sources: Philippine HIV/AIDS Registry (as of December 2013) Philippine Integrated HIV Behavioral & Serological Surveillance EPP/Spectrum, UNAIDS Software 89% men Mode of transmission 93% sexual (73% among MSM) 4% needle/syringe sharing among PWID HIV prevalence < 1% among general population Cities with concentrated epidemics among MSM, PWID and FFSW (eg. Cebu City) HIV Data Sources: Philippine HIV/AIDS Registry (as of December 2013), and Philippine Integrated HIV Behavioral & Serological Surveillance EPP/Spectrum, UNAIDS Software Cebu Manila MSM = men who have sex with men, PWID = people who inject drugs, FFSW = female freelance sex workers

Quick facts about PWID in Metro Cebu Source: DOH NEC IHBSS 2013 * Data source: IHBSS survey 2013 Median age of respondents (n=767)* 30 yrs (15-56) Age of first drug use (Median) 16 yrs Age of first Injection (Median) 19 yrs % injecting nalbuphine98% Average number of injections/day 3 (1-12) % PWID tested and knew their HIV status in last year 6% Metropolitan Cebu # of PWID (2011 estimate) Cebu city2,017 Other cities3,983 Total6,000 PWID = people who inject drugs

A public health crisis in Cebu, Philippines (HIV) HIV Data Sources: Philippine HIV/AIDS Registry (as of December 2013), Philippine Integrated HIV Behavioral and Serological Surveillance EPP/Spectrum, UNAIDS Software

A public health crisis in Cebu, Philippines (Hepatitis C) Data Sources: Philippine Integrated HIV Behavioral & Serological Surveillance EPP/Spectrum, UNAIDS Software, Hepatitis C prevalence

Delay in response due to conflicting laws The Philippines AIDS Prevention and Control Act of 1998 (RA8504) Support HIV response in sex workers and people who inject drugs Access to HIV prevention Improving quality of life Dangerous Drug Act of 2002 (RA9165) Impedes HIV response: – Arrest Mere possession of needles as injecting paraphernalia (even without drugs) Caught visiting area known to be drug dens – Problem for peer educators bringing clean needles/ syringes to the community

Delay in response due to ‘Chicken and Egg’ situation Central level expects local government to take initiative in harm reduction, and policy making based on local experience Local government waits for clear health policy guidance from central government, before action is taken

Advocacy & technical assistance to set up NSP in Cebu Development of advocacy briefing paper –Fact finding –Packaging HIV epi data for stakeholders Share international harm reduction experiences Advocacy meetings including training of police Drafting proposal for community-based pilot of harm reduction programme NSP = needle and syringe programme

Advocacy works… good work continues… Drug use is a multiple health problem, PWID should NOT be seen as criminals Access to essential health commodities (condoms, needles/syringes) is a human right A public health approach (harm reduction) improves public security PWID = people who inject drugs

Quotes from a catholic Brother P. - religious group speaking at police training workshop “Love is above law!” “Asking permission is difficult, but asking forgiveness is easy” If a Catholic Brother can do (distributing needles/syringes and condoms) for the sake of saving lives, who else cannot?

Consensus among key stakeholders Finding a local solution for a local problem

‘One-stop shop’ comprehensive harm reduction in Cebu social hygiene clinic 1.Needle and syringe program 2.HIV counseling and testing 3.Antiretroviral therapy 4.Management of sexually transmitted infections 5.Condom programme for PWID and their partners 6.Targeted information, education, communication and psychosocial services for PWID and their partners 7.Vaccinations, diagnosis and treatment of Viral Hepatitis 8.Prevention, diagnosis and treatment of TB* 9.Referral for voluntary rehabilitation

Source of dada: Cebu social hygiene clinic-progress report, 2014 PWID = people who inject drugs

Lessons learned… so far Social hygiene clinic based NSP - a model fits well the Philippines Dedicated manager/staff essential, and more trained staff in demand to ensure quality of services and use of data Strong support from DoH, PWID community, NGOs from HIV-positive groups and faith-based organizations WHO local consultant provides direct support and facilitates additional assistance in time Working with police possible! Increased police understanding of public health solution to HIV crisis as public security DoH = Department of Health NSP = needle and syringe programme

The way forward Continue advocacy to enforcement agencies (including city lawyers) to sustain the local enabling environment, with a vision to reform the drug policy/laws Strengthen and monitor current programme to ensuring the quality of services and use of data Extend the current facility-based services to community-based Replicate Cebu model to other cities which have HIV among PWID (e.g. under the GF new funding model)

Acknowledgements Jerson See, Cebu Plus Association, the Philippines Mark Arnejo, Cebu Plus Association Floyd'Maldepena, Cebu Plus Association Daisy Villa, Cebu City Health Department Teresita Rodriguez, Cebu City Health Department Gary Reid, Independent consultant Nerissa Dominquez, WHO Philippines Ying-Ru Lo, WHO Western Pacific Regional Office

Thank you! Is there any existing experience on Nalbuphine substitution treatment? What about Buprenorphine? Terumo Insulin Syringes - 29G U cc 1/2" - BX 100