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Research Article

Trends and emerging directions in HIV risk and prevention research in the Philippines: A systematic review of the literature

Contributed equally to this work with: Arjee Restar, Mary Nguyen

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, United States of America

Roles Data curation, Methodology, Project administration, Software, Writing – review & editing

Roles Data curation, Methodology, Visualization, Writing – review & editing

Roles Data curation, Formal analysis, Methodology, Software, Visualization, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Writing – review & editing

Affiliation Department of Behavioral Sciences, University of the Philippines, Manila, Philippines

• Arjee Restar, 
• Mary Nguyen, 
• Kimberly Nguyen, 
• Alexander Adia, 
• Jennifer Nazareno, 
• Emily Yoshioka, 
• Laufred Hernandez, 
• Don Operario

• Published: December 5, 2018
• https://doi.org/10.1371/journal.pone.0207663
• Reader Comments

The Philippines is experiencing one of the fastest growing epidemics globally. Evidence-based public health policies are needed. To describe the public health literature on HIV risk groups and prevention approaches in the Philippines, we reviewed published empirical studies with HIV-related outcomes.

Based on an a priori systematic review protocol, we searched PubMed, PsycINFO and CINAHL databases for quantitative studies conducted in the Philippines that reported on HIV risk groups factors and interventions to prevent HIV. The search included studies published as of April 2018.

We identified 755 records, screened 699 unique titles and abstracts, and conducted full text review of 122 full reports of which 51 articles met inclusion criteria. The majority were cross-sectional studies describing HIV and STI prevalence and risk factors in samples recruited from the Philippines. Four HIV prevention programs conducted in the Philippines were identified, all of which reported improvements on HIV knowledge, attitudes, and behaviors. Overall, female sex workers (FSWs) constituted the primary study population, and few studies reported data from men who have sex with men (MSM), people who inject drugs (PWIDs), and youth. No studies reported on transgender populations. Most studies were focused on examining condom use-related outcomes and STI history, few had biomarkers for HIV, and none addressed biomedical HIV prevention strategies.

This review identifies an agenda for future HIV research that is needed to address the growing and shifting nature of the HIV epidemic in the Philippines.

Citation: Restar A, Nguyen M, Nguyen K, Adia A, Nazareno J, Yoshioka E, et al. (2018) Trends and emerging directions in HIV risk and prevention research in the Philippines: A systematic review of the literature. PLoS ONE 13(12): e0207663. https://doi.org/10.1371/journal.pone.0207663

Editor: Jerome T. Galea, University of South Florida, UNITED STATES

Received: July 16, 2018; Accepted: November 5, 2018; Published: December 5, 2018

Copyright: © 2018 Restar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data can be found in Table 1 of the paper and our search strategy is detailed in our methods section.

Funding: Study was supported by National Institutes of Health(NIH)-Fogarty D43TW010565, NIH-NIAID P30AI042853, Brown University Global Health Scholars program, and the Robert Wood Johnson Foundation (RWJF) Health Policy Research Scholars program (awarded to Arjee Restar). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, Brown University, nor RWJF.

Competing interests: The authors have declared that no competing interests exist.

Introduction

After the first HIV case was identified in the Philippines in 1984, the country’s estimated HIV prevalence had remained low for over two decades [ 1 ]. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS)’s surveillance reports, the Philippines’ progress towards reaching HIV/AIDS 90-90-90 treatment for people living with HIV and knowing their HIV status (67%), on treatment (32%), and are virally suppressed (29%), is slow as HIV infections rise in the Philippines [ 2 ]. National surveillance data showed that the number of new HIV cases in the Philippines started to rise at an alarming rate during the past decade, with an increase from 311 cases identified in 2007 to 8,151 cases identified in 2016 –representing a 26-fold increase in new HIV diagnoses [ 3 ]. According to a 2014 national report, 93% of HIV cases in the Philippines were transmitted through sexual contact and were particularly concentrated among youth and young adults [ 4 ].

Despite the growing HIV epidemic in the Philippines, there have been challenges in mobilizing local and national HIV prevention, education, and testing programs [ 5 , 6 ]. Evidence-based public health is needed. However, a 2015 report by the World Health Organization (WHO) highlights that the body of HIV research conducted in the Philippines has been limited across all areas, including prevention, epidemiology, evaluation, and behavioral science, which are each essential to developing effective public health strategies [ 7 , 8 ].

Some of the recognized key populations for HIV risk in the Philippines include men who have sex with men (MSM), transgender people, female sex workers (FSW), youth, and overseas workers [ 1 , 6 , 7 ]. Although the estimated number of people who inject drugs (PWID) in the Philippines has been historically low, there have been anecdotal reports suggesting a growth in this population [ 9 ]. The National AIDS and STI Prevention and Control Program for the Philippines has urged for the development of HIV prevention and public health initiatives targeted towards key populations [ 7 ]. However, an external review by the WHO of the national response acknowledged multi-level challenges in implementing HIV prevention and treatment activities, including a misalignment of healthcare priorities in the national- and city-level settings, limited healthcare infrastructure and human resources to provide prevention and treatment services to key populations, and a nascent research literature on which to build evidence-informed strategies [ 7 ].

We conducted a systematic review to examine the body of empirical literature on HIV risk and intervention programs in the Philippines. Our specific aims were to synthesize findings about population characteristics associated with HIV status or HIV risk in the Philippines, to identify and describe local HIV prevention interventions evaluated in the Philippines, and to describe the methodological characteristics of this body of research. As a secondary aim, we sought to describe differences in reported HIV risk in studies conducted before 2008 compared with studies published during or after 2008, which represents the year during which national surveillance observed noted increased HIV cases.

We conducted this systematic review in accordance with guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist [ 10 ], which can be found in S1 Fig . Fig 1 displays the flowchart of review’s article section, inclusion and exclusion.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0207663.g001

Search strategy

We searched for quantitative studies assessing biological or behavioral indicators of HIV risk among Filipino/a participants in the Philippines. Studies were included if they: 1) were conducted in the Philippines; 2) sampled Filipino/a participants; 3) published in English; 4) reported quantitative findings on any of the following category of outcomes: biological risk for HIV (biomarkers/biologically confirmed HIV or other STIs); self-reported HIV status or STI diagnoses or symptoms; HIV-related sexual risk behavior (such as condomless sex, commercial sex, sex under influence of drugs/alcohol, sex with partner of HIV-positive or unknown status); injection drug use; knowledge, attitudes and beliefs relating to HIV/AIDS risk and transmission. We did not limit studies according to type of quantitative design (i.e., cross-sectional, intervention trial, etc.) or presence of a comparison or control group.

Electronic searches of PubMed, PsycINFO, and CINAHL were carried out using an a priori search strategy in April 2018. The search strategy included validated MeSH terms for HIV as well as terms related to Philippines. For example, the PubMed search used the following terms: [HIV* OR AIDS* OR HIV Infections[MeSH] OR HIV[MeSH] OR hiv[tw] OR hiv-1*[tw] OR hiv-2*[tw] OR hiv1[tw] OR hiv2[tw] OR hiv infect*[tw] OR human immunodeficiency virus[tw] OR human immunodeficiency virus[tw] OR human immuno-deficiency virus[tw] OR human immune-deficiency virus[tw] OR ((human immuno*) AND (deficiency virus[tw])) OR acquired immunodeficiency syndrome[tw] OR acquired immunodeficiency syndrome[tw] OR acquired immuno-deficiency syndrome[tw] OR acquired immune-deficiency syndrome[tw] OR ((acquired immuno*) AND (deficiency syndrome[tw])) OR “Sexually Transmitted Diseases, Viral”[MeSH:NoExp]] and Philippines. The search strings were intended to be conservative to first capture articles that relevant to the scope of the study and then identify articles meeting inclusion criteria.

This search yielded 755 records (see Fig 1 for a flowchart of the systematic review process). A team of reviewers received training in applying the inclusion criteria to research records; reviewers applied the screening criteria to an initial batch of 100 records and discussed discrepancies until reliability was achieved. Screeners were instructed to apply initial inclusion criteria liberally, such that records were retained in the search process until the team was sure that studies did not meet inclusion criteria. After excluding 56 duplicate records from the database, two reviewers screened the remaining 699 records resulting in a shortlist of 122 records that appeared to meet inclusion criteria based on information in the title or abstract. These articles were retrieved for full text review, which was performed by four reviewers (including the 2 previous reviewers) who identified 51 articles that met inclusion criteria. We excluded 71 articles because they were not based in the Philippines, were not empirical studies (i.e. editorials, commentaries, or reviews), or did not report on outcomes specified for this review. We identified several articles meeting inclusion criteria that reported different findings from the same parent research study; these articles were retained in this review.

Data extraction and analysis

The overarching goal of this review was to summarize trends in the published literature and appraise the methodological quality of identified studies. For all research articles that met inclusion criteria, we extracted information about the year(s) of data collection, study sample and location, sampling method, study design, HIV-related outcome(s), and main findings (see Table 1 ). Articles that reported data from the same parent study are grouped together in Table 1 , with the primary or lead article denoted by superscript “a” and subsequent articles denoted by “b”, “c”, etc.

https://doi.org/10.1371/journal.pone.0207663.t001

Narrative synthesis of studies was conducted based on information extracted into Table 1 . Because of heterogeneity in sampling approaches, time, and indicators of HIV risk across studies, meta-analysis was not conducted. We assessed methodological characteristics of each study using a critical appraisal checklist developed by Munn and colleagues [ 11 ]. These methodological characteristics included sample representativeness, recruitment strategies, adequacy of sample size, participant drop-out or non-response, description of setting and participant, objective criteria for outcome measurements, reliability of outcome, appropriateness of statistical analysis, accounting of confounding factors, and identification of sub-populations.

Authors were not blind to any aspect of the studies. Funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Characteristics of included studies

Table 1 presents characteristics of 51 included articles from 30 independent studies. Twenty-five articles reported quantitative findings from independent studies [ 12 – 36 ]. Two articles reported analyses from a cross-sectional survey of sexual behaviors among adult men and women from Cebu (a large metropolitan city in the Philippines) [ 37 – 38 ]. Fifteen articles reported analyses from a longitudinal, quasi-experimental investigation of a community-based HIV prevention program involving female bar workers and managers in four regions of the Philippines [ 39 – 53 ]. Four articles reported findings from a quasi-experimental intervention to prevent HIV and STIs among heterosexuals in southern Philippines [ 54 – 57 ]. Two articles reported analyses of a survey of people who inject drugs in Manila, Cebu, and Davao cities [ 58 – 59 ]. Three articles reported analyses of a survey of FSW recruited from entertainment establishments in metro Manila [ 60 – 62 ].

Overall, data collection for the included studies occurred between years 1985 to 2015. Of 30 independent studies, most (n = 18) studies reported findings from data collected before 2008 and 10 studies reporting findings from data collected during or after 2008; 2 studies did not specify year of data collection, but both were published before 2008. Sample sizes per study ranged from 62 to 144,000; the latter study involved analysis of blood bank data. Female sex workers (e.g., registered and freelance) constituted the most frequently studied population (n = 11 unique studies). Fewer studies reported data on MSM (n = 3 unique studies), PWID (n = 3 unique studies), youth (n = 4 unique studies), seafarers (n = 3 unique studies), or incarcerated females (n = 1 study). One study reported on overseas worker candidates [ 35 ]. No included studies reported data on overseas workers and transgender populations, and no studies reported data on gender expression or gender identity indicators.

The majority of articles (n = 43) reported descriptive data from cross-sectional designs (including baseline data from intervention evaluations). Only 4 independent intervention studies were identified, with evaluation findings reported across 9 different articles [ 17 , 32 , 39 , 41 , 42 , 47 , 48 , 54 , 55 ].

Ten articles reporting data from 9 independent studies reported prevalence of HIV-positive status [ 13 , 20 , 21 , 23 , 24 , 31 , 34 , 39 , 58 , 59 ]. HIV prevalence across studies ranged from 0% (in 3 independent studies of 560 female and male adults in Cebu [ 13 ], 62 blood donor samples from Manila [ 20 ], and 100 incarcerated females in Manila [ 31 ]) to 52.0% in a sample of 457 participants in Cebu who were recruited using respondent driven sampling [ 34 ]. Of the 9 independent studies reporting HIV prevalence, 6 were conducted before 2008 (HIV prevalence ranging from 0.0% [ 12 , 20 , 31 ] to 0.2% [ 24 ]) and 3 were conducted after 2008 (HIV prevalence ranging from 3.3% [ 58 ] to 52.0% [ 34 ]).

Nineteen studies reported STI diagnosis or symptoms [ 12 , 13 , 15 , 16 , 18 , 20 , 24 , 25 , 29 , 31 , 33 , 35 , 36 , 37 , 39 , 43 , 50 , 52 , 58 ]. Of those studies, four studies included Hepatitis C [ 13 , 24 , 36 , 58 ], three included Hepatitis B and gonorrhoeae each [ 13 , 18 , 20 , 31 , 35 ], two included chlamydia [ 31 , 35 ], and one for trichomonas and HPV each [ 31 , 33 ]. Reported prevalence ranged from a low of 0.4% in a sample of overseas Filipino worker candidates and blood donors who tested positive for Hepatitis B virus or Hepatitis C virus [ 36 ], to 63.1% history of any STI in a sample of FSW from Cebu [ 12 ]. There were no clear trends in reports of STI prevalence in studies conducted before versus after 2008.

Behavioral risk factors.

Commonly reported HIV risk factors included self-reported condom use, and substance use behaviors. Of the included articles, thirty-one reported condom use behaviors. Assessment of condom use varied widely across studies, including measures of condomless sex with different partner types (e.g., with sex workers, multiple sexual partners, group sex, regular partners, and casual partners), frequency of condom use (e.g., using condoms always, consistently, inconsistently, and never), condom use according to type of intercourse (e.g., condom use during vaginal or anal sex), and condom use according to specific sexual events (e.g., condom use at first sex, and during last sexual encounter). Assessment of condom attitudes and knowledge also varied, with measurements including knowing that condoms prevent HIV/AIDS, pregnancy, and STI infections, as well as feeling that condoms reduce sexual pleasure or enjoyment, and that using condoms is against religion. Only five studies reported substance use outcome measures [ 21 , 34 , 38 , 57 , 62 ], and these studies varied with regard to assessment about type, frequency, and amount of substance use.

Intervention programs.

We identified a total of four independent intervention studies aiming to prevent HIV transmission, with evaluation results reported across 9 reports [ 17 , 32 , 39 , 41 , 42 , 47 , 48 , 54 , 55 ]. One intervention study conducted in 1995 by Aplasca et al. [ 17 ] involved a cluster-randomized trial of a school-based program to improve HIV-related knowledge, attitudes, and behaviors among high school students in Manila. Findings included improved levels of knowledge about HIV biology, transmission and prevention, as well as improved attitudes and compassion for people living with HIV in the intervention versus control groups; no effects were found on intentions to engage in preventative behaviors [ 17 ]. Another intervention study conducted in 2013 by Urada et al. [ 32 ] involved a human-rights focused HIV intervention for sex workers in Manila. Participants completed a single 4-hour intervention providing HIV and STI knowledge and prevention strategies, and contextualized risk and protective factors in accordance with the laws, systems, and social milieu regarding sex work, violence, and discrimination. In pre-post analysis, participants reported higher levels of knowledge about HIV reproductive health, human rights, research ethics, and intentions to receive an HIV test [ 32 ].

Two intervention programs were quasi-experimental studies. First, a 3-year study conducted from 1994–1998 by Morisky et al. [ 39 ] used community-based participatory methods to train managers and peer educators on HIV and STI prevention at 130 entertainment establishments in 4 regions in the Philippines. Trained managers and peers then implemented and disseminated information within their establishments. In post-test evaluation analyses, FSW employed in these establishments reported significant improvements in consistent condom use, improvements in HIV testing, and reductions in STI infections [ 39 , 42 , 47 , 48 ]. Additional analyses showed that improvements in condom use were strongest in establishments that also instituted condom use policies for employees and patrons [ 41 ]. Second, a 3-year quasi-experimental study conducted from 2000–2005 by Morisky et al. [ 54 ] used community-based participatory methods to provide HIV prevention education training to peer leaders recruited from six male populations in the southern Philippines: military members, police and firemen, construction workers, taxi drivers, pedicab drivers, and community residents; trainees were then expected to educate 10 or more peer network members on HIV and STI prevention. In post-test evaluation analyses, intervention participants reported lower levels of STI infections as well as improvements in HIV and STI knowledge, attitudes toward condoms, condom use behavior, discussion about HIV with co-workers, and exposure to HIV prevention education, compared with those in the control [ 54 , 55 ].

Finally, another prospective STI treatment study was identified, but was not considered a scalable HIV prevention intervention compared with the four studies described here. In this STI treatment study conducted in 1996–1997 by Aplasca de los Reyes et al. [ 18 ], FSWs from Manila and Cebu testing positive for N . gonorrhoeae were randomly assigned to receive a single dose of ciprofloxacin (500 mg) or a single dose of cefixime (400 mg), and were re-evaluated 4–7 days later. Findings showed high rates of treatment failure and resistance in participants who received ciprofloxacin and adequate effects for single-dose cefixime [ 18 ].

Methodological appraisal of the included studies.

For selecting participants, most of the study participants were recruited using sampling methods based on non-randomized sampling strategies, including convenience and purposive sampling such as venue-based (e.g., community or establishment) recruitment approaches or from surveillance studies. Common examples of venue-based recruitments were via bars, nightclubs, karaoke TV lounges, massage parlors, and health clinics. One study reported data from a nationally representative youth survey [ 19 ], and two studies reported data from respondent driving sampling surveys [ 34 , 58 ]. Although all studies indicated the type of recruitment strategy used (e.g., convenience sampling, etc.), almost 13 did not specifically detail about how participants were recruited. All studies had adequate sample size to perform analysis, and had high participant response rate. Most studies (n = 26) provided adequate description of their participant samples and the study settings.

When considering outcomes, nineteen studies did not use objective standard criteria for measuring outcomes (i.e., validity) such as a biologically-confirmed results. Self-reported outcomes were primarily assessed and there were noticeable inconsistent measurements in condom use and substance use behavioral measures and HIV-related knowledge and attitude measures. Statistical analyses for each study were conducted appropriately based on study design. Of the four intervention studies, one used a cluster randomized control trial design, two used non-randomized comparison groups, and one used a pre-post evaluation design. Intervention studies assessed self-report behavioral outcomes only; none measured biological or objective indictors of HIV risk.

Despite the rise in HIV infections documented in the Philippines’ national surveillance reports since 2008, this review highlights the limited body of published research on HIV infection and risk factors in key populations, a paucity of research on interventions to promote HIV prevention and testing in the Philippines, and opportunities for improving methodological rigor in future research. Overall, we identified 51 published quantitative papers reporting on HIV- or STI-related biological, behavioral, or social-cognitive findings from 30 unique studies conducted in the Philippines. The majority of papers identified in this review reported on data collected before 2008; only 10 papers (reporting on 7 discrete studies) reported data collected during or after 2008. Moreover, this review identified only 4 HIV prevention intervention evaluations in the published literature.

Prior to 2008, FSWs constituted the population most frequently studied in HIV research conducted in the Philippines. After 2008, a small number of studies included MSM and PWID. Indeed, the papers by Gangcuangco and colleagues [ 21 ] and Telan and colleagues [ 59 , 60 ] and are among the only identified published studies which recruited and reported specifically on HIV risk in MSM populations. Findings from PWID were included in four reports–one involving surveillance data from an earlier phase of the epidemic [ 16 ], three conducted after 2008 by Verdery and colleagues [ 34 ] and by Telan and colleagues [ 58 , 59 ]. Four studies included youth; two were conducted before 2008 [ 17 , 19 ] and two after [ 28 , 38 ]. No identified studies specifically reported on overseas workers and transgender populations.

This review identifies a need to improve the body of knowledge about HIV risk and transmission among key populations in the Philippines. Research targeting MSM, PWID, and transgender populations is needed to understand the transmission risk factors and specific structural, social, behavioral, and epidemiological factors impacting these groups. While there is a considerable body of HIV prevention intervention research focusing on MSM and PWIDs in other parts of the world [ 63 , 64 ], none have been specific to the Philippines. It remains unclear whether existing prevention interventions are adaptable or require distinct design for this national context. Additionally, despite an estimated global HIV prevalence of 19% [ 65 ], and anecdotal reports that suggests a growing burden of HIV among transgender women in the Philippines [ 66 ], none of the included studies have focused on or included this key population. It is possible that researchers in the Philippines have aggregated transgender populations within the MSM rubric [ 67 ]. Given HIV epidemiological trends within the Philippines and evidence from other settings about the disproportionate prevalence of HIV among transgender people, future research must disaggregate transgender and MSM populations and resist the conflation of gender and sexual identities [ 68 ]. Additionally, given that UNAIDS surveillance data points to youth and young adults being affected [ 2 ], more biological and behavioral research data and interventions are necessary to understand the epidemic among youth and young adults in the Philippines, especially those who are also members of MSM, PWID, or transgender populations.

Most of the studies identified in this review used cross-sectional surveys with convenience samples, involving mostly descriptive measures, which limit the generalizability of the research. While these study designs are useful in exploratory investigations, it is imperative for researchers to increase the rigor of investigations by using longitudinal and experimental studies in order to examine more complex research hypotheses (e.g., testing hypotheses about social-behavioral determinants of HIV infection) and to test interventions [ 68 ].

Moreover, as the majority of includes studies were conducted prior 2008, researchers must also examine biomedical factors that might determine or mitigate the growth of HIV in the Philippines–e.g., factors associated with medication adherence and viral load suppression among PLHIV (i.e., treatment-as-prevention), access to and use of biomedical prevention such as post-exposure prophylaxis and pre-exposure prophylaxis, home-based testing, and male-circumcision. Given the political climate regarding drug use in the Philippines, the viability of harm reduction and needle exchange programs for HIV prevention must be carefully considered [ 69 , 70 ].

The literature identified in this review was also noteworthy with regard to the scarcity of investigation into psychosocial and ecological factors that contribute to HIV risk, mental health, personal and community empowerment, stigma, and substance use. While it is important to continue assessing condom use-related measures in key populations, it is imperative that researchers examine contextual conditions and co-morbid health factors associated with low condom use as well as the broader social-structural drivers of HIV risk and infection, in order to understand factors affecting the acceptability and feasibility of bio-behavioral preventative strategies.

Taken together, these findings provide initial insight into the increasing and shifting HIV epidemic in the Philippines, from an initial concentration among FSWs to including populations such as MSM and PWIDs. These findings also suggest the need to develop social-contextual frameworks to prioritize HIV prevention strategies and contextualize HIV risk/prevention according to the lived experiences of key populations. Assessment of clinical and service provider capacities in responding to HIV risk and infections is also important to guide research and build a stronger public health infrastructure.

Limitations of this review must be considered. First, although this review followed a systematic search protocol and a priori inclusion criteria, it is possible that not all relevant articles were identified. Second, meta-analysis was not deemed appropriate due to heterogeneity in samples, methods, measures, and time of data collection. Third, the review included only English-language publications. Fourth, the generalizability of the review might be limited given the specificity of the context for this review and the ongoing evolution of the Philippines’ national epidemic.

This is the first known systematic review to provide evidence about and identify gaps in published research about risk groups, risk factors, and intervention approaches addressing the Philippine’s HIV epidemic. Studies revealed a nascent body of literature, especially with regard to intervention research, biomedical prevention, and key populations currently impacted by the HIV epidemic such as PWIDs, MSM, and transgender populations. Future HIV research studies in the Philippines must use rigorous research methodologies including purposeful sampling strategies and validated measures (including biological assessments for HIV and STIs, and established measures for substance use, condom use, and mental health). Furthermore, given the evolving epidemic in the Philippines, researchers should capitalize on opportunities to implement and evaluate bio-behavioral intervention strategies including pre-exposure prophylaxis, treatment-as-prevention, and regular HIV testing with key populations. Use of online data recruitment and data collection approaches can improve access to hard-to-reach or remote populations; online research might be especially useful for reaching members of historically stigmatized groups. A multi-disciplinary research agenda for understanding and addressing HIV transmission in the Philippines must span across various domains of research including prevention, epidemiology, treatment, and behavioral and social science.

Supporting information

S1 fig. prisma checklist (2009)..

https://doi.org/10.1371/journal.pone.0207663.s001

Acknowledgments

Study was supported by National Institute of Health (NIH)-Fogarty D43TW010565, NIH-NIAID P30AI042853, Brown University Global Health Scholars program, and the Robert Wood Johnson Foundation Health Policy Research Scholars program (awarded to Arjee Restar). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, Brown University, nor RWJF.

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HIV/AIDS risk in the Philippines : focus on adolescents and young adults

This paper focuses on HIV/AIDS risk in the Philippines, especially adolescents and young adults.

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• Published: 24 November 2021

A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data

• Shobhit Srivastava   ORCID: orcid.org/0000-0002-7138-4916 1 ,
• Shekhar Chauhan   ORCID: orcid.org/0000-0002-6926-7649 2 ,
• Ratna Patel   ORCID: orcid.org/0000-0002-5371-7369 3 &
• Pradeep Kumar   ORCID: orcid.org/0000-0003-4259-820X 1  

Scientific Reports volume  11 , Article number:  22841 ( 2021 ) Cite this article

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Acquired Immunodeficiency Syndrome caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. This study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with the change in awareness level on HIV-related information among adolescents over the period. Data used for this study were drawn from Understanding the lives of adolescents and young adults, a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh. The present study utilized a sample of 4421 and 7587 unmarried adolescent boys and girls, respectively aged 10–19 years in wave-1 and wave-2. Descriptive analysis and t-test and proportion test were done to observe changes in certain selected variables from wave-1 (2015–2016) to wave-2 (2018–2019). Moreover, random effect regression analysis was used to estimate the association of change in HIV awareness among unmarried adolescents with household and individual factors. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2 to 39.1% between wave-1 & wave-2. With the increase in age and years of schooling, the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV. Adolescent boys' paid work status was inversely associated with HIV awareness [Coef: − 0.01; p  < 0.10]. Use of internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness with reference to their counterparts. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups, as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents.

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Introduction.

Acquired Immunodeficiency Syndrome (AIDS) caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. So far, HIV has claimed almost 33 million lives; however, off lately, increasing access to HIV prevention, diagnosis, treatment, and care has enabled people living with HIV to lead a long and healthy life 1 . By the end of 2019, an estimated 38 million people were living with HIV 1 . More so, new infections fell by 39 percent, and HIV-related deaths fell by almost 51 percent between 2000 and 2019 1 . Despite all the positive news related to HIV, the success story is not the same everywhere; HIV varies between region, country, and population, where not everyone is able to access HIV testing and treatment and care 1 . HIV/AIDS holds back economic growth by destroying human capital by predominantly affecting adolescents and young adults 2 .

There are nearly 1.2 billion adolescents (10–19 years) worldwide, which constitute 18 percent of the world’s population, and in some countries, adolescents make up as much as one-fourth of the population 3 . In India, adolescents comprise more than one-fifth (21.8%) of the total population 4 . Despite a decline projection for the adolescent population in India 5 , there is a critical need to hold adolescents as adolescence is characterized as a period when peer victimization/pressure on psychosocial development is noteworthy 6 . Peer victimization/pressure is further linked to risky sexual behaviours among adolescents 7 , 8 . A higher proportion of low literacy in the Indian population leads to a low level of awareness of HIV/AIDS 9 . Furthermore, the awareness of HIV among adolescents is quite alarming 10 , 11 , 12 .

Unfortunately, there is a shortage of evidence on what predicts awareness of HIV among adolescents. Almost all the research in India is based on beliefs, attitudes, and awareness of HIV among adolescents 2 , 12 . However, few other studies worldwide have examined mass media as a strong predictor of HIV awareness among adolescents 13 . Mass media is an effective channel to increase an individuals’ knowledge about sexual health and improve understanding of facilities related to HIV prevention 14 , 15 . Various studies have outlined other factors associated with the increasing awareness of HIV among adolescents, including; age 16 , 17 , 18 , occupation 18 , education 16 , 17 , 18 , 19 , sex 16 , place of residence 16 , marital status 16 , and household wealth index 16 .

Several community-based studies have examined awareness of HIV among Indian adolescents 2 , 10 , 12 , 20 , 21 , 22 . However, studies investigating awareness of HIV among adolescents in a larger sample size remained elusive to date, courtesy of the unavailability of relevant data. Furthermore, no study in India had ever examined awareness of HIV among adolescents utilizing information on longitudinal data. To the author’s best knowledge, this is the first study in the Indian context with a large sample size that examines awareness of HIV among adolescents and combines information from a longitudinal survey. Therefore, this study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with a change in awareness level on HIV-related information among adolescents over the period.

Data and methods

Data used for this study were drawn from Understanding the lives of adolescents and young adults (UDAYA), a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh 23 . The first wave was conducted in 2015–2016, and the follow-up survey was conducted after three years in 2018–2019 23 . The survey provides the estimates for state and the sample of unmarried boys and girls aged 10–19 and married girls aged 15–19. The study adopted a systematic, multi-stage stratified sampling design to draw sample areas independently for rural and urban areas. 150 primary sampling units (PSUs)—villages in rural areas and census wards in urban areas—were selected in each state, using the 2011 census list of villages and wards as the sampling frame. In each primary sampling unit (PSU), households to be interviewed were selected by systematic sampling. More details about the study design and sampling procedure have been published elsewhere 23 . Written consent was obtained from the respondents in both waves. In wave 1 (2015–2016), 20,594 adolescents were interviewed using the structured questionnaire with a response rate of 92%.

Moreover, in wave 2 (2018–2019), the study interviewed the participants who were successfully interviewed in 2015–2016 and who consented to be re-interviewed 23 . Of the 20,594 eligible for the re-interview, the survey re-interviewed 4567 boys and 12,251 girls (married and unmarried). After excluding the respondents who gave an inconsistent response to age and education at the follow-up survey (3%), the final follow-up sample covered 4428 boys and 11,864 girls with the follow-up rate of 74% for boys and 81% for girls. The effective sample size for the present study was 4421 unmarried adolescent boys aged 10–19 years in wave-1 and wave-2. Additionally, 7587 unmarried adolescent girls aged 10–19 years were interviewed in wave-1 and wave-2 23 . The cases whose follow-up was lost were excluded from the sample to strongly balance the dataset and set it for longitudinal analysis using xtset command in STATA 15. The survey questionnaire is available at https://dataverse.harvard.edu/file.xhtml?fileId=4163718&version=2.0 & https://dataverse.harvard.edu/file.xhtml?fileId=4163720&version=2.0 .

Outcome variable

HIV awareness was the outcome variable for this study, which is dichotomous. The question was asked to the adolescents ‘Have you heard of HIV/AIDS?’ The response was recorded as yes and no.

Exposure variables

The predictors for this study were selected based on previous literature. These were age (10–19 years at wave 1, continuous variable), schooling (continuous), any mass media exposure (no and yes), paid work in the last 12 months (no and yes), internet use (no and yes), wealth index (poorest, poorer, middle, richer, and richest), religion (Hindu and Non-Hindu), caste (Scheduled Caste/Scheduled Tribe, Other Backward Class, and others), place of residence (urban and rural), and states (Uttar Pradesh and Bihar).

Exposure to mass media (how often they read newspapers, listened to the radio, and watched television; responses on the frequencies were: almost every day, at least once a week, at least once a month, rarely or not at all; adolescents were considered to have any exposure to mass media if they had exposure to any of these sources and as having no exposure if they responded with ‘not at all’ for all three sources of media) 24 . Household wealth index based on ownership of selected durable goods and amenities with possible scores ranging from 0 to 57; households were then divided into quintiles, with the first quintile representing households of the poorest wealth status and the fifth quintile representing households with the wealthiest status 25 .

Statistical analysis

Descriptive analysis was done to observe the characteristics of unmarried adolescent boys and girls at wave-1 (2015–2016). In addition, the changes in certain selected variables were observed from wave-1 (2015–2016) to wave-2 (2018–2019), and the significance was tested using t-test and proportion test 26 , 27 . Moreover, random effect regression analysis 28 , 29 was used to estimate the association of change in HIV awareness among unmarried adolescents with household factors and individual factors. The random effect model has a specific benefit for the present paper's analysis: its ability to estimate the effect of any variable that does not vary within clusters, which holds for household variables, e.g., wealth status, which is assumed to be constant for wave-1 and wave-2 30 .

Table 1 represents the socio-economic profile of adolescent boys and girls. The estimates are from the baseline dataset, and it was assumed that none of the household characteristics changed over time among adolescent boys and girls.

Figure  1 represents the change in HIV awareness among adolescent boys and girls. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2% in wave-1 to 39.1% in wave-2.

The percenate of HIV awareness among adolescent boys and girls, wave-1 (2015–2016) and wave-2 (2018–2019).

Table 2 represents the summary statistics for explanatory variables used in the analysis of UDAYA wave-1 and wave-2. The exposure to mass media is almost universal for adolescent boys, while for adolescent girls, it increases to 93% in wave-2 from 89.8% in wave-1. About 35.3% of adolescent boys were engaged in paid work during wave-1, whereas in wave-II, the share dropped to 33.5%, while in the case of adolescent girls, the estimates are almost unchanged. In wave-1, about 27.8% of adolescent boys were using the internet, while in wave-2, there is a steep increase of nearly 46.2%. Similarly, in adolescent girls, the use of the internet increased from 7.6% in wave-1 to 39.3% in wave-2.

Table 3 represents the estimates from random effects for awareness of HIV among adolescent boys and girls. It was found that with the increases in age and years of schooling the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV in comparison to those who had no exposure to mass media. Adolescent boys' paid work status was inversely associated with HIV awareness about adolescent boys who did not do paid work [Coef: − 0.01; p  < 0.10]. Use of the internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness in reference to their counterparts.

The awareness regarding HIV increases with the increase in household wealth index among both adolescent boys and girls. The adolescent girls from the non-Hindu household had a lower likelihood to be aware of HIV in reference to adolescent girls from Hindu households [Coef: − 0.09; p  < 0.01]. Adolescent girls from non-SC/ST households had a higher likelihood of being aware of HIV in reference to adolescent girls from other caste households [Coef: 0.04; p  < 0.01]. Adolescent boys [Coef: − 0.03; p  < 0.01] and girls [Coef: − 0.09; p  < 0.01] from a rural place of residence had a lower likelihood to be aware about HIV in reference to those from the urban place of residence. Adolescent boys [Coef: 0.04; p  < 0.01] and girls [Coef: 0.02; p  < 0.01] from Bihar had a higher likelihood to be aware about HIV in reference to those from Uttar Pradesh.

This is the first study of its kind to address awareness of HIV among adolescents utilizing longitudinal data in two indian states. Our study demonstrated that the awareness of HIV has increased over the period; however, it was more prominent among adolescent boys than in adolescent girls. Overall, the knowledge on HIV was relatively low, even during wave-II. Almost three-fifths (59.9%) of the boys and two-fifths (39.1%) of the girls were aware of HIV. The prevalence of awareness on HIV among adolescents in this study was lower than almost all of the community-based studies conducted in India 10 , 11 , 22 . A study conducted in slums in Delhi has found almost similar prevalence (40% compared to 39.1% during wave-II in this study) of awareness of HIV among adolescent girls 31 . The difference in prevalence could be attributed to the difference in methodology, study population, and study area.

The study found that the awareness of HIV among adolescent boys has increased from 38.6 percent in wave-I to 59.9 percent in wave-II; similarly, only 30.2 percent of the girls had an awareness of HIV during wave-I, which had increased to 39.1 percent. Several previous studies corroborated the finding and noticed a higher prevalence of awareness on HIV among adolescent boys than in adolescent girls 16 , 32 , 33 , 34 . However, a study conducted in a different setting noticed a higher awareness among girls than in boys 35 . Also, a study in the Indian context failed to notice any statistical differences in HIV knowledge between boys and girls 18 . Gender seems to be one of the significant determinants of comprehensive knowledge of HIV among adolescents. There is a wide gap in educational attainment among male and female adolescents, which could be attributed to lower awareness of HIV among girls in this study. Higher peer victimization among adolescent boys could be another reason for higher awareness of HIV among them 36 . Also, cultural double standards placed on males and females that encourage males to discuss HIV/AIDS and related sexual matters more openly and discourage or even restrict females from discussing sexual-related issues could be another pertinent factor of higher awareness among male adolescents 33 . Behavioural interventions among girls could be an effective way to improving knowledge HIV related information, as seen in previous study 37 . Furthermore, strengthening school-community accountability for girls' education would augment school retention among girls and deliver HIV awareness to girls 38 .

Similar to other studies 2 , 10 , 17 , 18 , 39 , 40 , 41 , age was another significant determinant observed in this study. Increasing age could be attributed to higher education which could explain better awareness with increasing age. As in other studies 18 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , education was noted as a significant driver of awareness of HIV among adolescents in this study. Higher education might be associated with increased probability of mass media and internet exposure leading to higher awareness of HIV among adolescents. A study noted that school is one of the important factors in raising the awareness of HIV among adolescents, which could be linked to higher awareness among those with higher education 47 , 48 . Also, schooling provides adolescents an opportunity to improve their social capital, leading to increased awareness of HIV.

Following previous studies 18 , 40 , 46 , the current study also outlines a higher awareness among urban adolescents than their rural counterparts. One plausible reason for lower awareness among adolescents in rural areas could be limited access to HIV prevention information 16 . Moreover, rural–urban differences in awareness of HIV could also be due to differences in schooling, exposure to mass media, and wealth 44 , 45 . The household's wealth status was also noted as a significant predictor of awareness of HIV among adolescents. Corroborating with previous findings 16 , 33 , 42 , 49 , this study reported a higher awareness among adolescents from richer households than their counterparts from poor households. This could be because wealthier families can afford mass-media items like televisions and radios for their children, which, in turn, improves awareness of HIV among adolescents 33 .

Exposure to mass media and internet access were also significant predictors of higher awareness of HIV among adolescents. This finding agrees with several previous research, and almost all the research found a positive relationship between mass-media exposure and awareness of HIV among adolescents 10 . Mass media addresses such topics more openly and in a way that could attract adolescents’ attention is the plausible reason for higher awareness of HIV among those having access to mass media and the internet 33 . Improving mass media and internet usage, specifically among rural and uneducated masses, would bring required changes. Integrating sexual education into school curricula would be an important means of imparting awareness on HIV among adolescents; however, this is debatable as to which standard to include the required sexual education in the Indian schooling system. Glick (2009) thinks that the syllabus on sexual education might be included during secondary schooling 44 . Another study in the Indian context confirms the need for sex education for adolescents 50 , 51 .

Limitations and strengths of the study

The study has several limitations. At first, the awareness of HIV was measured with one question only. Given that no study has examined awareness of HIV among adolescents using longitudinal data, this limitation is not a concern. Second, the study findings cannot be generalized to the whole Indian population as the study was conducted in only two states of India. However, the two states selected in this study (Uttar Pradesh and Bihar) constitute almost one-fourth of India’s total population. Thirdly, the estimates were provided separately for boys and girls and could not be presented combined. However, the data is designed to provide estimates separately for girls and boys. The data had information on unmarried boys and girls and married girls; however, data did not collect information on married boys. Fourthly, the study estimates might have been affected by the recall bias. Since HIV is a sensitive topic, the possibility of respondents modifying their responses could not be ruled out. Hawthorne effect, respondents, modifying aspect of their behaviour in response, has a role to play in HIV related study 52 . Despite several limitations, the study has specific strengths too. This is the first study examining awareness of HIV among adolescent boys and girls utilizing longitudinal data. The study was conducted with a large sample size as several previous studies were conducted in a community setting with a minimal sample size 10 , 12 , 18 , 20 , 53 .

The study noted a higher awareness among adolescent boys than in adolescent girls. Specific predictors of high awareness were also noted in the study, including; higher age, higher education, exposure to mass media, internet use, household wealth, and urban residence. Based on the study findings, this study has specific suggestions to improve awareness of HIV among adolescents. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents. Investment in education will help, but it would be a long-term solution; therefore, public information campaigns could be more useful in the short term.

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This paper was written using data collected as part of Population Council’s UDAYA study, which is funded by the Bill and Melinda Gates Foundation and the David and Lucile Packard Foundation. No additional funds were received for the preparation of the paper.

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Srivastava, S., Chauhan, S., Patel, R. et al. A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data. Sci Rep 11 , 22841 (2021). https://doi.org/10.1038/s41598-021-02090-9

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Introduction.

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A model HIV/AIDS risk reduction programme in the Philippines: a comprehensive community-based approach through participatory action research

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Donald E. Morisky, Alfonso Ang, Astou Coly, Teodora V. Tiglao, A model HIV/AIDS risk reduction programme in the Philippines: a comprehensive community-based approach through participatory action research, Health Promotion International , Volume 19, Issue 1, March 2004, Pages 69–76, https://doi.org/10.1093/heapro/dah109

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A 3-year, longitudinal, quasi-experimental study using participatory action research (PAR) was conducted to determine the feasibility and efficiency of an expanded sexually transmitted infection (STI) HIV/AIDS prevention program among diverse high-risk male heterosexual populations in the southern Philippines. A total of 3389 participants (∼200 males from each of 18 study groups) were recruited, and 221 were trained as peer counselors to develop educational materials and reinforce safe sexual practices among their peers. Condom usage (36.10% to 38.70% to 46.31%), attitudes towards condoms (21.67% to 24.55% to 25.15%) and knowledge about HIV/STI transmission (41.87% to 42.19% to 33.31%) increased significantly from baseline to post-test and 6-month follow up, respectively ( p < 0.01). Furthermore, the reported STI incidence decreased significantly (7.4% to 4.6% to 2.4%, respectively). Changes differed significantly between the intervention and control group at post-test and follow up ( p < 0.01). These findings illustrate the appropriateness of using PAR methodology in promoting and sustaining positive behavior change.

Of the estimated 40 million persons who are currently infected with HIV worldwide, 7.1 million live in South and South-East Asia. In 2001, the epidemic claimed the lives of 435 000 persons in this region ( UNAIDS/WHO, 2001 ). Low HIV prevalence in this area still results in high numbers of infections as this region includes highly populated countries such as China, India and Indonesia. It is therefore important to implement health promotion and disease prevention programs to avert epidemics in countries where HIV prevalence is still low. One such country is the Philippines.

In the Philippines, infection rates in general, even among the high-risk groups, have remained at low levels (<1%) ( UNAIDS/WHO, 2000 ). The National HIV Sentinel Surveillance System (NHSSS) was implemented in two major cities, beginning in 1993 and expanded to 10 cities by 1996 throughout the entire archipelago ( Department of Public Health, 2001 ). Behavioral sentinel surveillance was added to NHSSS in 1997 to monitor trends in knowledge and behaviors of vulnerable groups (injecting drug users, registered and freelance female sex workers, and men having sex with men).

A participatory research process

This paper reports the results of an innovative community-based participatory research program in the Philippines targeting the heterosexual male clients of commercial sex workers (CSW). Clients of CSW constitute a significant risk group that may benefit from educational and behavioral interventions to improve HIV knowledge, attitudes and practices concerning HIV and sexually transmitted infection (STI). Such efforts are crucial to avert an HIV epidemic in the Philippines. The present study sought to achieve those goals using a participatory action research (PAR) approach. PAR is defined as ‘systematic inquiry, with the collaboration of those affected by the issue, for the purposes of education or effecting social change’ ( George et al ., 1999 ). The PAR approach is characterized by six major criteria: (i) it is participatory; (ii) it is cooperative; (iii) it is a co-learning process; (iv) it involves systems development and local capacity building; (v) it is an empowering process for participants; and (vi) it achieves a balance between research and action ( Israel et al ., 1998 ). One of the main characteristics of PAR is that it eliminates the traditional distinction between the ‘researchers’ and the ‘researched’ ( Gaventa, 1981 ). Both HIV/AIDS researchers and community-based organizations are partners and responsible for the conceptualization, needs analysis, development, implementation and evaluation of the program. As a result of this process, community participants are empowered with the realization of their own capabilities to be researchers and to induce desired changes within their communities ( Hagey, 1997 ). This method seems particularly suitable when one is conducting research on controversial or sensitive issues such as HIV/AIDS.

Most educational efforts in the early phase of the HIV/AIDS pandemic have been concentrated on the high-risk groups, particularly CSW, men having sex with men, and intravenous drug users. In the same light, the first project launched jointly by the School of Public Health, University of California Los Angeles, and the College of Public Health, University of the Philippines, entitled ‘Behavioral Science in Support of HIV/AIDS Prevention’, also focused on CSW and managers/owners of the entertainment establishments utilizing an organizational change behavioral approach, including educational policy in the establishment ( Tiglao et al ., 1996 ; Morisky et al ., 1998 ). Results of this programmatic effort indicated significant improvements in condom use behaviors and reduction of STI among female bar workers ( Morisky et al ., 2002a ; Morisky et al ., 2002b ; Morisky et al ., 2002c ). However, in order to have a comprehensive program in the community, the customers of the CSW need to be included as well.

It is clear that men still dominate women's sexual behavior. It is recognized that men are generally more sexually active, have more sexual intercourse than the general female population, have more sexual partners, and generally take risks to maintain their machismo image to the extent that they refuse to practice safe sex. In short, they have a major role in the transmission of STI and HIV/AIDS. As a result of this, the second phase of the research was entitled ‘Comprehensive Community Based STI/HIV/AIDS Prevention Project’, which focused on the high-risk male client populations. Very few studies have assessed multiple intervention programs targeting a diverse male population using a variety of health education/promotion strategies and a PAR component.

Study population

The research was conducted in six study areas in the southern Philippines, namely: Lapu-Lapu and Mandaue City in Metropolitan Cebu; Legaspi and Daraga in the Bicol Region; and Cagayan de Oro City in Mindanao and Cavite City in the southern Tagalog Region. The six male population study groups were: (i) the military (air force); (ii) police and firemen; (iii) industrial workers; (iv) taxicab drivers; (v) pedicab drivers; and (vi) community ( barangay ) residents.

A comprehensive community-based approach using a crossover study design was employed in the study. Baseline assessments were obtained with respect to HIV/AIDS knowledge, attitudes toward condoms, and condom use behavior in a 3-year longitudinal study. The six study groups were compared with post-intervention surveys (conducted 12 months following the training session) and follow-up surveys to evaluate the effectiveness of the intervention.

Table 1 displays the longitudinal crossover research design, with phase I and phase II of the intervention. All study groups were assessed at baseline (months 1–3), phase 1 interventions in study groups 1 and 3 (months 4–15), post-test assessment for all study groups (months 16–18), phase 2 interventions for study groups 2 and 4 (months 19–30), and finally follow-up assessment for all study groups (months 31–33). This design enabled all six study groups to participate in the intervention/training program, as well as allowing for the assessment of both short- and long-term impact of outcome indicators.

Research design

O 1 , O 2 and O 3 represent the baseline, post-test and follow-up assessment, respectively.

X 1 and X 2 represent the peer education intervention.

Social preparation and the participatory process

Prior to the initiation of the intervention phase of the project, which in a way also served as a form of intervention, the collaboration of the City Health personnel, the Mayors and other city officials was sought in each of the six targeted sites. Executive officers, managers, military commanders and supervisors of each of the target populations were likewise oriented on the magnitude of the STI/HIV/AIDS problem and the importance of male involvement in the prevention of STI/HIV/AIDS. Each of these groups were invited to serve on local advisory committees

Sample size of target groups

The entire population of males in each targeted site was invited to participate in the study following informed consent procedures. Most of the time, this amounted to ∼200 individuals from each of the study populations. Study groups included one entire squadron of air force personnel, the packing and bottling division of industrial factory workers, the entire adult male population (18–45 years) from the community ( barangay ) located near the commercial sex establishment, and the total population of taxi and pedicab drivers from four sites. These study groups are representative of the entire population of males in each of the targeted sites. For the air force personnel, one squadron was randomly selected out of a total of four squadrons. Preliminary analysis revealed that this squadron is similar in demographic characteristics to the other remaining squadrons not selected in the study site, and presented no selection bias. Participation rate in each of the selected sites was high, ranging from 99% to 100%. A total of 3389 males participated in the 3-year longitudinal study.

An interview schedule to measure knowledge, attitudes and practices related to STI/HIV/AIDS was used, including a 20-item, five-point scale which included questions on perceived level of knowledge, HIV/STI/AIDS transmission and risk of getting AIDS (α reliability = 0.81). Attitude towards condoms was measured by a seven-item, five-point scale (α reliability = 0.86). Participants were also asked a series of questions (yes/no) pertaining to condom use, STI incidence, discussion of AIDS with co-workers, attendance of AIDS prevention classes, and whether they received AIDS educational materials.

Gaining access to the community: presentation of baseline results

The coordinators of each of the six intervention sites arranged for presentation of baseline results to the entire group of participants. This included an overview of the problem of HIV/AIDS in Asia as well as the Philippines. Data were presented on cognitive indicators (knowledge, beliefs and attitudes) as well as behavioral determinants (condom use, multiple-sex partners and STI infection). Following this presentation of baseline information, speakers from the academe, the Department of Health and non-governmental organizations (NGOs) provided information on different types of STI with an emphasis on HIV/AIDS and its modes of transmission, and various methods of STI prevention, underscoring the importance of practicing safe sex (condom use), followed by demonstrations and role playing on the proper use of condoms. Slides and video presentations ensured lively discussion among participants.

Before the seminars ended, 10–20 peer counselors from each target group were recruited either by unanimous choice of the group, volunteering, or recommendation by their supervisors. Peer counselors attended a 1-day workshop, which included: a review of the technical aspects of STI/HIV/AIDS transmission and control; discussion of some of the myths about STI/HIV/AIDS and clarification of issues; skill-building teaching methods and strategies; counseling techniques; how to prepare Information, Education and Communication (IEC) materials; and how to use flip charts on HIV/AIDS. The flip chart was provided for each peer counselor during the training program. All peer counselors engaged in role plays simulating peer counseling activities. Resource speakers from the City Health Department Social Hygiene Clinic, NGOs, other government sectors (education and social welfare), and at times private clinician specialists on STIs were used as resource persons during the training.

Following this training session, peer counselors were expected: to educate at least 10 of their peers on STI/HIV/AIDS prevention; to meet with the site coordinator regularly to report the progress of their work; to conceptualize and develop IEC materials on STI/HIV/AIDS, including posters, stickers and photonovellas; and to distribute IEC materials on STI/HIV/AIDS to their co-workers. The photonovelas developed can be viewed online ( Morisky, 2002c ).

Peer counselors meet with the site coordinator every week for ∼1 h to go over the baseline data (at the aggregate level) specific to their own organization. Counselors review frequencies, request cross tabulations of different variables (such as how are attitudes towards condom use related to condom use behavior), and begin to construct a diagnostic assessment of the educational and counseling needs of their fellow co-workers. This process continued for ∼2 months, at which time educational responses to the identified needs were to be developed, including posters, fliers, brochures, stickers and photonovellas, or picture story presentations of common situations and events. One of the major activities of the peer educator was the conceptualization and development of the photonovella and posters and stickers. This proved a very productive process, evolving over several brain-storming sessions. Important diagnostic findings were conceptualized into story boards and scripts. As peer counselors clarified the facts and what went through the process, they unconsciously internalized the concept of STI/HIV/AIDS prevention. This was the most important component of the participatory research process in which the participants themselves developed and produced the educational responses to the diagnostic findings from the baseline needs assessment. Each study group produced their own photonovella, posed for pictures and translated the original English versions into the local dialect ( Morisky, 2002c ). The finished product was distributed to their peers. The posters were displayed in strategic places and the stickers placed in taxis and pedicabs.

Throughout the intervention, peer counselors and researchers identified and discussed specific problems arising at their sites. This strategy of identifying community needs and problems, highlighting the strategies used to engage in successfully influencing community development, has proven to be an effective modality in effecting change within the community ( Wadsworth, 1998 ).

Demographics

The socio-demographic characteristics of the participants and their peer counselors obtained at baseline were not significantly different. The mean age of the participants was 34.7 years. Sixty-seven percent were married, and had worked in their jobs for an average of 10 years. The mean educational level of the participants was 10.7 years of schooling.

Knowledge, attitudes and beliefs surrounding HIV/AIDS

Knowledge about HIV/STI transmission increased significantly from baseline to post-test and 6-month follow up in the intervention group (see Table 2 ). The control group's knowledge about HIV/STI was not significantly different from the intervention group at baseline and remained constant at post-test and follow up.

Comparison of knowledge and attitudes between the intervention and control group in the study

p < 0.01.

Similarly, there was no significant difference in attitude towards condoms at baseline between the intervention and control group; however, at post-test and follow up there were significant differences in condom use attitude between the intervention and the control group, with scores significantly increasing for the intervention group.

Reported STIs and condom use

The number of respondents who had ‘ever used condoms’ increased significantly among participants in the intervention group (38.7% to 46.3%) but not in the control group (33.79% to 38.72%) during the post-test and the follow-up period (see Table 3 ). Furthermore, there was a significant difference in the responses between peer counselors and regular participants at post-test ( t = 2.5, p < 0.01) and follow up ( t = 2.6, p < 0.009). Among respondents in the intervention group who had sex with CSW, the condom usage ‘during the last time’ they had sex also increased significantly from post-test to follow up for peer counselors (13.36% to 18.65%), but condom usage remained unchanged for the control group (11.08% to 11.81%). Peer counselors reported a significantly higher condom usage ‘during the last time’ they had sex compared with regular participants in the study in the post-test ( t = 2.2, p < 0.02) and follow-up period ( t = 2.60, p < 0.009).

Comparison of condom use practice and STI infections between the intervention ( n = 1819) and control groups ( n = 1570) in the study

p < 0.05.

After the intervention, there was a decrease in the number of participants who reported having an STI episode. Self-reported STI incidence decreased among participants from 4.6% to 2.4% versus 6.9% to 5.8% for the control group. There was a significant difference in the reported STI incidence between regular participants and peer counselors at post-test ( t = 2.59, p < 0.009) and follow up ( t = 2.71, p < 0.008).

A more detailed analysis of condom use behavior revealed that in the high-risk population (barangay residents), condom usage with CSW was not significant at post-test, but increased significantly at follow up (from 29% to 55%). Additionally, we found that among those who declared that they did not have sexual intercourse, condom use with CSW increased significantly for the industrial factory workers (18% to 30%) and for the taxi drivers (17% to 21%) from post-test to follow-up. Among tricycle drivers and military personnel, however, condom use increased at post-test, but the level of condom use at follow up was below that observed at baseline. And in the police/fireman group, condom usage decreased at both post-test and follow up ( Table 4 ).

Condom use behavior: sexual intercourse with CSWs

Monitoring community participation, peer influence and policy change

In order to monitor community participation, individuals were asked whether they had ever discussed HIV/STI prevention with their co-workers, and whether they had ever attended an AIDS prevention workshop or seminar. Participants were also asked whether they ever received educational materials on AIDS/STI prevention from their employers.

The number of respondents who had ‘ever discussed HIV/AIDS with their co-workers’ increased significantly in the intervention group (51.9% to 54.9%), but not in the control group during the post-test and the follow-up period ( Table 3 ). Furthermore, there was a significant difference in the responses between peer counselors and regular participants during the post-test ( t = 3.52, p < 0.001) and follow-up periods ( t = 4.81, p < 0.001). The participation in HIV/STI prevention workshops increased significantly from post-test to follow up among participants in the intervention group (22.0% to 32.0%), but not in the control group (6.2% to 5.8%). Peer counselors reported a significantly higher participation in HIV/STI prevention workshops compared with the other participants in the study during the post-test ( t = 2.8, p < 0.003) and the follow-up periods ( t = 2.7, p < 0.008).

The number of respondents who received educational materials on HIV/STI prevention from their employers increased significantly from post-test to follow up in the intervention group (88.0% to 90.4%), but not in the control group (70.2% to 72.4%). There was a significant difference between regular participants and peer counselors who received the educational materials during the post-test ( t = 2.6, p < 0.007) and the follow-up period ( t = 2.9, p < 0.001).

The theoretical benefits of using a participatory peer education approach are well discussed in the literature. However, little information on the application and efficacy of community-based participation research methods in actual projects has been reported ( Higgins and Metzler, 2001 ). This study reports the results of a PAR intervention program. It stresses the impact of the intervention on risk reduction and includes a comparison of the incremental difference the intervention had for peer counselors compared with the regular participants. The theoretical concept behind peer education is relative simple. People with the same cultural background, experience and lifestyles are more effective teachers within that group compared with outsiders. Since peer counselors are selected within the group, they share the same concerns and have similar values and norms to the rest of the community that they work within. Peer counselors also have more access to influence the group, provide a more credible and trusted source of information, and can constantly reinforce safe sexual practices in a culturally sensitive manner, thereby enhancing the educational learning process.

The reported condom usage increased significantly after the intervention, and along with this, the reported STI incidence also decreased significantly. The key factors for the success of the intervention included the fact that the peer counselors were able to understand important issues within the target group and develop educational materials that were culturally sensitive and easily understood by other participants in the study. The intervention overcame barriers of discussing sensitive issues like HIV, STI and condoms because the peer counselors were carefully selected, and were considered influential leaders among the different groups. The peer counselors were instrumental in developing culturally appropriate photonovellas that depict HIV/STI prevention in the form of a pictorial narrative illustrating different scenarios that can be easily understood, assimilated and accepted by the other participants in the group.

A more detailed analysis was also made of condom use behavior with CSW for the different types of client-centered populations (i.e. high-risk barangay residents, factory workers, taxi drivers, tricycle drivers, police/firemen and military). The results indicate that the intervention effect is not always apparent at post-test, but becomes meaningfully significant at follow up. For example, for the high-risk population ( barangay residents), condom usage with CSW was not significant at post-test, but increased significantly at follow up (from 29% to 55% condom usage, respectively). This result suggests a delay in the impact of the educational strategy that was not observed at post-test, but as other factors intervened over time (peer support, social influence, organizational policy) the behavior change became evident ( Green, 1977 ). However, since the findings also indicate that the intervention did not have the desired effect on condom use in some target groups, the results of the intervention may be considered somewhat mixed.

In order to be effective, peer education needs to be maintained over a long period of time. Other studies on peer education have reported that without continuing motivation and maintenance, momentum is diminished ( Hayman et al ., 1996 ). When support for the program decreased, knowledge and reported condom use declined but still remained at the pre-intervention levels. Follow-up evaluation for at least 6 months beyond the post-test has to be conducted to correctly assess the maintenance of the behavioral changes as a result of the intervention. In this study, if condom use had been assessed only at post-test, only minor changes would have been identified.

Monitoring participation and peer influence during the course of the intervention is important. In this research, discussion about HIV/AIDS among co-workers was assessed at baseline, post-test and follow up, and the effect was found to be significant from post-test to follow up, indicating maintenance of change. Participants also attended more HIV/AIDS-prevention workshops after the intervention, and received more educational materials on HIV/STI prevention from their employers. These measured effects, which reflect the degree of participation from the individuals (i.e. attendance, discussion, etc.) and the employers (distribution of education materials to employees), are important factors that help promote the success of this intervention.

PAR involves a process of cooperation and active participation among community members. In this research, the different communities were found to be cooperative and willing to participate in the program. The use of peer counselors was found to be an effective tool for increasing knowledge, improving attitudes towards more favorable condom use, and encouraging and sustaining appropriate behavior change.

We extend appreciation to the City Health Officers who provided access to the study sites, CEOs and managers of study sites, participants who enrolled in the program, peer counselors who provided educational counseling and site coordinators who provided ongoing training and management of the program. This research was supported by grant R01-AI33845 from the National Institutes of Allergy and Infectious Diseases to D. E. M.

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Author notes

1University of California, Los Angeles, CA, USA and 2University of the Philippines, Manila, the Philippines

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