Local Government Academy Department of the Interior and Local Government

Practices that Work: HIV and AIDS Local Response in the Philippines

Published by: Local Government Academy

All rights reserved. Parts of this publication may be reproduced with proper acknowledgement.

Writers: Elyzabeth F. Cureg Raphael N. Montes, Jr.

Substance Editors: Institutional Partnership Unit – LGA Patrick Omar B. Erestain Karl Abalos Sly Z. Barrameda

Copy Editor: Layout and Design:

All rights reserved. Copyright 2014

Local Government Academy 8/F Agustin 1 Building. F. Ortigas Jr. Road (formerly Emerald Avenue) Ortigas Center, Pasig City, 1605 Philippines Tel. no.: (632) 634 8430 / 634 8436 www.lga.gov.ph/hiv

List of Acronyms v

Introduction viii

Chronicles of Success Foretold 1 BAGUIO CITY

For Many are Called 12 SANTIAGO CITY

From Troubled Teens to Power Peers 21 PARAÑAQUE CITY

Guarding the Backdoor 30 ZAMBOANGA CITY

Everybody’s Business 42 PROVINCE OF AKLAN

A Different Battlefield 56 PROVINCE OF NORTH COTABATO

AAI Abante Aklan, Inc. AIDS acquired immunodeficiency syndrome AFRHS Adolescent Friendly Reproductive Health Services ALS alternative learning system AOP Annual Operating Plan APAC Aklan Provincial HIV and AIDS Council APAFZ Association of Partners for an AIDS-Free Zamboanga APEC Asia Pacific Economic Cooperation AWAC (Baguio) AIDS Watch Council BALUTI Batang Laging Umiiwas sa Tiyak na Impeksyon BANS Baguio Association of Night Spots BARS Bars and Restaurants Association of Baguio City BASULTA Basilan, Sulu, Tawi-tawi BB Butterfly Brigade BCYA Baguio Center for Young Adults BHW Barangay Health Worker BIMP-EAGA Brunei-Indonesia-Malaysia-Philippines East Asia Growth Area BLAACP Barangay Legal Action Against Child Prostitution CHAMP (Local) Catalytic Actions for HIV and AIDS Mitigation Programme CHD Center for Health Development CHO City Health Office CLGOO City Local Government Operations Officer COM Crossover Mission CSC Civil Service Commission CSO civil society organizations CSW commercial sex workers DepEd Department of Education DILG Department of the Interior and Local Government DOH Department of Health DOJ Department of Justice DOLE Department of Labor and Employment DRSTMH Doctor Rafael S. Tumbokon Memorial Hospital EEW establishment entertainment workers EO Executive Order FHI Family Health International

FSW freelance sex workers; female sex workers GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GGP Gawad Galing Pook GRO guest relations officer HDES Human Development and Empowerment Services HIV human immunodeficiency virus HSO Health Service Office IDU injecting drug user IEC information, education and communication IPHO Integrated Provincial Health Office IT information technology KTV karaoke tv LAC Local AIDS Council LEGSC League of Enthusiastic Gays in Santiago City LGU local government unit LMP League of Municipalities of the Philippines MARP most-at-risk populations MIU Men in Uniform MOP Manual of Procedures MSM men having sex with men NASPCP National AIDS-STI Prevention and Control Program NEC National Epidemiology Center NGO non-government organizations OCSWDO Office of the City Social Welfare and Development Office OFW overseas Filipino workers PEC Peer Educators Council PHO Provincial Health Office PIA Philippine Information Agency PLHIV People Living with HIV and AIDS PMS premarital sex PNP Philippine National Police PPDO Provincial Planning and Development Office PPP Public-Private Partnership RA Republic Act RAAT Regional AIDS Assistance Team RH reproductive health RHWC Reproductive Health and Wellness Center SCMS Santiago City Medical Society SEBAS Santiago Entertainment Business Association

SEC Securities and Exchange Commission SHC Social Hygiene Clinic SK Sangguniang Kabataan SSOA Shindig Stall Owners Association STI sexually transmitted infections SWDO Social Welfare and Development Office TESDA Technical Education and Skills Development Authority TWG Technical Working Group UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund USAID United States Agency for International Development VAW Violence against women VCT voluntary counseling and testing WAD World AIDS Day ZCMSAC Zamboanga City Multi-Sectoral AIDS Council ZEA Zamboanga Entertainment Association

The rise in the number of HIV and AIDS cases in the Philippines continue to alarm the world. The country’s epidemic is described as “hidden and growing”. Commitments to halt this epidemic have launched efforts both at the national and local levels. Local Government Academy’s Program on Scaling-up Effective and Sustained Response on HIV and AIDS is one such effort.

In partnership with the United Nations Development Programme, initiatives focused on developing the leadership capacities of local governments and the Regional AIDS Assistance Teams in providing sustainable local AIDS responses. Aside from capacity building, research and publication and technical assistance, the Program launched the local C.H.A.M.P. (Catalytic Actions for HIV and AIDS Mitigation Programme) Award.

Local CHAMP recognizes the good practices of local governments in addressing the HIV and AIDS problem and in improving services to their target clientele. The awards started in 2010 and the practices of six LGU winners are featured in this publication. The stories and experiences in four cities (Baguio, Santiago, Parañaque, Zamboanga) and 2 provinces (Aklan, North Cotabato) were captured primarily through document and literature review and interviews.

BAGUIO CITY. The story outlines the pioneering ideas and actions of the city since 1987, eleven years before the enactment of RA 8504. Readers would learn that the city was the first to create a local AIDS Council, first to recruit the active participation of the private sector, and to practice the STI Syndromic Case Reporting System. The city’s internationally recognized Bonjing website and its fun and jam-packed Annual WAD Conference is also a good practice to discover. Not surprisingly, the City’s RHWC was once noted as the best and most ideal facility, being able to offer quality and comprehensive package of services for PLHIVs and the general populace alike.

SANTIAGO CITY. The city enjoyed a relatively long HIV-free period, until the first case was recorded in 2011. Their local response nevertheless started as early as 2008. The city exhibits foresight and astuteness in effectively building a functional multi-sectoral coalition that jointly works to strengthen HIV and AIDS advocacy efforts. It also introduced the mobile awareness booth that roams around the town’s public places, schools and institutional complexes together with the volunteer peer educators who serve as the information personnel.

PARAÑAQUE CITY. The city showed that delinquents-to-role model approach is a risky but fulfilling strategy if applied correctly. Deviating from the basic peer counseling methodology, the self-help initiative of a dozen alcoholics/addicts/gang members through the initial support of Save the Children, grew into what is the Adolescent-Friendly RH Services in Parañaque City. Officially founded under the B.A.L.U.T.I. program, the BALUTI together with the City Health Office manages both the community- based and school-based activities that is grounded on their effective Give Me 5 Communication Approach.

ZAMBOANGA CITY. Recognizing the threats not only locally but also from the neighboring countries, the City championed the cause when it created and enriched the membership of the Multi-Sectoral AIDS Council. It also organized the at-risk groups and customized programs for IDUs. It saw the need to prepare IEC materials in Chavacano and to beef up the composition of inspection activities of its Task Force Buenas. All in all, the city welcomed all possible partners from all walks of life.

AKLAN PROVINCE. The province led in the formation of a multi-sectoral collaboration that capitalizes on the expertise of member-partners in fighting the HIV and AIDS problem in Aklan. It reached out to the youth, gay community, CSOs, academe and media. This collaboration was instrumental in the design of creative IEC campaigns and the creation of the Peer

Educators Council. Every December, the WAD celebration is a reflection of the concerted efforts of all Council/Collaboration members.

NORTH COTABATO PROVINCE. This is an interesting case featuring an RH/HIV/AIDS awareness program for men in uniform (MIU). In partnership with development aid agencies, the province managed the conduct of a series of training activities for selected military battalions. Peer facilitators were identified from each of the platoons. As a result, rate of condom use as well as MIU availing vasectomy procedures increased.

These six cases are excellent examples of meaningful and life-changing undertakings on HIV and AIDS. They show that local governments and community organizations can make a difference. Size does not matter when passion, compassion and competence are present. These cases present practices that work, even against a huge enemy like HIV and AIDS.



Their moment of submission of the awards application document is like a foretelling. The flow of events would clearly suggest the ending. There is no doubt in anyone familiar with their story that Baguio City would win the 2011 Local C.H.A.M.P Award.

THE SETTING

Baguio, located in the Province of Benguet and 250 kilometers north of Manila, is a first class city. Its 129 barangays occupy 57.5 square kilometers of land. As of 2010, its estimated population is 318,676 representing almost 20% of the regional total. It is a migration destination, with half of its population aged 25 years and younger. The operation in the city of about 8 tertiary education institutions more or less explains for the population’s youthfulness.

Aside from being an education center, Baguio city is also a hub of commercial and trade activities in northern Philippines. This complements its touristic character. The city is known for its pine forests, elevated altitude, high value vegetables, flower festival and cool climate. It consistently gets a place in the top 10 favorite tourism destinations in the Philippines. This is most probably because it is considered the summer capital of the country, given its temperate weather. Annual visitor arrival averages at 709,020 (2006-2012), 94.5% of which are domestic travelers.

Baguio city, being a migration, education and tourism magnet, makes it a hot area for the spread of HIV and AIDS. As of 2013, 18 lives of local residents have been lost to this dreadful disease since its first case was reported two decades past. The total number of recorded cases has reach

 apologies to Gabriel Garcia Marquez for the title inspiration.

59 (1992-2013). From new case droplets of 1 to 2 HIV infections in 1992 to 2003, broken only by 3 new cases in 1997, the number of new infections jumped to 6 in 2004. The number positively declined in 2005(3), 2006(4) and 2007-08(1-2). The year 2009 with 5 new reported cases seemed to signal a new phase. This was the year when the surveillance team discovered their youngest infected MSM. This also marked the continuing period of increasing number of case reports. Only 2012 offered a let up with just 2 new case reports. But figures for 2010(6), 2011(8) and 2013(8) seemed to suggest an imminent battle against the 2-digit mark.

The 59 total registered cases come from 17 to 45 age range, more than a majority of which are males (44). Half of these males are men having sex with men (MSM). Note that 18 of the patients are overseas Filipino workers. The trend gives the impression of higher risk from young MSMs, seeing that 10 of the 24 cases since 2010 are young people and 6 of the 8 new cases for 2013 are MSM.

CHRONOLOGY OF EVENTS AND INITIATIVES

The scenario is bleak but it would most likely be worse if Baguio City did not act fast enough. Alarmed of the first recorded HIV infection in the Philippines in 1984, the city government through the Health Department (now called Health Service Office or HSO) actively recruited the support of about 500 entertainers to voluntary undergo HIV tests.

By 1987, the city through HSO’s Social Hygiene Clinic (SHC) felt the need to form a local AIDS Council which they called the Baguio AIDS Watch Council (AWAC). This is the first of its kind in the country. In fact, it would take 11 more years before Congress would enact RA 8504 or the AIDS Prevention and Control Act. The council’s basic goal is to raise awareness to prevent any infection, envisioning an AIDS-free Baguio City. SHC of HSO served as the Secretariat and Dr. Charles Cheng, then Director of Baguio Filipino- Chinese General Hospital, served as the founding President. Even at the onset, AWAC officers mostly came from the private sector.

In 1992, the first reported case was registered. Three years after, the program Public-Private-Partnership (PPP) versus HIV/AIDS was conceptualized and introduced. It became the general approach to AWAC’s ensuing initiatives. The program rests on three principles:

(1) collaboration of AWAC members and its networks is necessary. Local government divisions like on social welfare (OCSWDO) and population office, national agencies like DOH, DOLE and DepEd, private sector partners like Baguio Center for Young Adults (BCYA) and Bars and Restaurants Association of Baguio City (BARS) have to learn to work together;

(2) complementation is important for the provision of optimum care and support. The weakness of a lean SHC with its 4-6 personnel complement and its limited resources and services will no longer be a weakness if supplemented with the commitment and support of partners and AWAC members;

(3) aggressive and massive information campaign is key to prevention.

DOH identified Baguio as the 10th sentinel site in 1996. SHC thus composed and led the Baguio HIV sentinel surveillance team to undertake the task. The other team members include the HSO staff, private practitioners, BCYA, and laboratory staff of the Baguio City General Hospital and Medical Center of DOH.

Two years after, SHC drafted a local legislation that seeks to institutionalize the HIV surveillance system in the city. The proposal was sponsored by Councilor Elmer Datuin of the Health and Sanitation Committee and it was enacted by 1998. This is another first for Baguio City.

Come 2000, AWAC registered itself as a non-government organization under the name Baguio AIDS Watch Council, Inc. It is a non-profit and multi- sectoral group composed of various representatives of both government and non-government institutions in Baguio. From the initial 2 partners in 1987, AWAC members grew to 15. It maintained SHC as its Secretariat.

Year 2000 was a busy one. The Baguio SHC pioneered the implementation of the STI Syndromic Case Reporting System in its different health districts. Participation of private doctors was critical with 75% of syndromic case reports coming from them. The system is basically about the reporting of STI diagnoses, based primarily from flowcharts and independent of laboratory results. To install the system, almost all health center health workers and select private physicians were asked to attend a short training on the subject. This reporting system was supposedly later adopted by DOH.

Another milestone in 2000 is the first UNDP-AWAC project. The Council got the support of the development agency for its intensive education campaign. The project revolved around the promotion and orientation of schools and city government employees on the provisions of the RA 8504. Guidance counselors from select public and private schools and even government offices were asked to attend. As for the city government employees, the orientation was participated by the different departments.

By December of the same year, AWAC through SHC led the organization of the Baguio Association of Night Spots (BANS). AWAC wanted to establish rapport with night workers and bar owners and get their support for awareness-raising and risk-reduction activities. The organization (BANS) later became BARS (Bars and Restaurants Association of Baguio City) which formed a corporate identity of its own. Together with the BANS and the HIV surveillance team, AWAC started the annual seminar series on HIV and AIDS. This was the precursor to what later would be converted into an Annual December Conference (beginning 2006). The focus of the first seminar was the no condom, no sex policy. It was also an opportunity for the AWAC to introduce the 3-condom policy; night workers should have in possession at least 3 condoms at any time during their service hours.

Jump four years after, 2004 was another busy and memorable year for the AWAC. It was able to forge stronger linkages with two non-government partners and introduce an IT-based peer education program. BCYA, an

AWAC member, was given the challenge of leading the MSM intervention track. BCYA helped the SHC to carry out STI screening, HIV pre- and post- test counseling and testing, syphilis testing and further counseling of MSMs. To do this, HSO gave BCYA a designated room at the 4th floor of HSO building.

Another partner, a ministry called Crossover Mission (COM) looked into the spiritual side of the HIV and AIDS problem. COM came over and reached out to what it considered as the “beloveds” of Baguio, primarily referring to night workers. COM, the latest AWAC member, is an NGO that provides spiritual growth, some livelihood assistance and even subscription in the alternative learning system (ALS) (since 2009). COM was allowed to use the AWAC room for its outreach programs to SHC clients. Basically, SHC refers to COM further interventions related to the spiritual, mental, social, cultural and even economic needs of SHC clients. COM also refers to SHC clients who may need STI/HIV services. COM ensures that all referred clients get to attend personality development and personality awakening sessions.

Another landmark engagement in 2004 to 2005 is the launching of the award-winning Bonjing e-inquiry (www.bonjing.org.ph). Conceptualized by Dr. Brillantes of SHC in 2004, it is a website where young people can seek information and counsel on RH, sex and HIV and AIDS concerns. The name is drawn from a Filipino term referring to a grown youngster who acts immature. The ultimate goal of the website is to develop health-seeking behavior among the youth. The idea is for young people to seek Bonjing as a friend, get them to reach out and share their sex and RH problems and needs, convince them to seek professional help and to eventually be able to bring them physically to a youth-friendly clinic in the city. It is akin to an online peer educator especially designed for the youth, which they can access any time at their convenience. SHC can also maximize Bonjing as a means of determining the knowledge, attitude and RH practices of Baguio city’s youth and assess their vulnerabilities to HIV.

Bonjing would respond within 24 hours of a client’s inquiry. Some of the common questions asked were on premarital sex (PMS) and its adverse consequences, sexually transmitted infections, contraceptives and substance abuse that lead to PMS and abortion. Three HSO divisions (SHC, Population Office, Health Education Promotion Office) with technical assistance from Management Information Technical division of the City Budget Office, comprise the Team Bonjing.

AWAC first provided for the website registration. Later, as part of counterpart initiatives to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATMR6) (2007-2009) through the Tropical Disease Foundation, AWAC secured the domain until 2013. Another partner which actively endorsed the site is the DepEd. Promoting it to both elementary and high school students and informing them of Bonjing drop boxes available in their schools. SHC was also able to get the support of the Rotary Club of Baguio for it to include Bonjing in its new generation program.

Bonjing was launch on May 2005, as part of the annual candlelight memorial. It is the city’s first interactive website and first for such a purpose in the Philippines. It won an international award from APEC (Asia Pacific Economic Cooperation) in Taipei in August 2005. DOH likewise recognized it as a best practice of the city government in preventing AIDS in 2008.

Back to 2005 though and even before the APEC award was given, it is supposedly a research team from the University of the Philippines who first acknowledged the HSO-SHC and AWAC’s good practices on STI and HIV prevention. The SHC staff felt that this is a turning point for them. They believed that this recognition somehow turned the tide of public perception, with SHC clients no longer as stigmatized as before. From then on, SHC has been receiving clients that do not necessarily fall under the most-at-risk-population (MARPs).

Then again, it was in 2006 when the Baguio SHC was considered as the ‘best’ and ‘most ideal’ facility. The Family Health International (FHI) and the National AIDS-STI Prevention and Control Program (NASPCP) of the DOH jointly undertook the monitoring of 10 big SHCs in the country. The monitoring was undertaken 6 months after the Manual of Procedures (MOP) for SHCs was introduced. The monitoring team outlined some of the good practices of Baguio City which received commendations on the following: (1) location, ambiance, space, supplies of clinic consultation room as most ideal; (2) use of new and modern fixtures as well as of disposable examination table sheets (duplicated later by other SHCs); (3) dedicated furnished and discrete counseling room; (4) adequate store room; (5) availability of all SHC services; (6) cleanliness, lighting and ventilation; (7) referral system feedback form; (8) well-maintained, accurate, complete records system.

The monitoring team likewise noted that the imposition of a dress code and proper client hygiene prior to consultation is a good practice. The dress code requires that women should not be in shorts, mini-skirts, pajamas, slippers and revealing tops while men must refrain from wearing shorts, sleeveless undershirts and slippers during consultation. This is to lessen stigma and discrimination.

Finally, before 2006 ended, HSO, SHC and AWAC organized the first of the annual HIV and AIDS Conference during the World AIDS Day. The conference took the place of the HIV seminar series started 6 years ago. The conference brought all the night workers together in one event to establish camaraderie among them and for them to have a common knowledge on HIV and AIDS, in the hope of persuading them to translate what they learn from the conference into practice.

The years 2007 to 2009 marked the city’s participation in the Global Fund project through the Tropical Disease Foundation. Among the activities AWAC through the SHC led, are the training of and peer educator outreach, enhancement of the STI referral network, and IEC engagement with BARS for the ABCs of STI/HIV prevention among moonlighters and entertainers.

The year 2007 also witnessed the passage of the SHC-drafted resolution providing for financial (livelihood) assistance to persons with HIV. Three patients were given Php10,000 worth support for the three types of livelihood (tamarind candy making, peanut butter jam making, fashion jewelry making).

It was also in 2007 when SHC decided to change its name to Reproductive Health and Wellness Center (RHWC) in compliance with the SHC MOP. All RHWC staff including the volunteers are granted as well the Civil Service Commission Gantimpala Award under its Mamamayan Muna Program. A year before, the SHC team was recognized by CSC as a Regional Pag-asa Awardee (group category).

In 2008, RHWC competently undertook the HIV surveillance without the assistance of DOH. In 2009, due to the youngest infected MSM discovered by the surveillance team, the team enlisted MSM partners to join them in the conduct of the surveillance.

In 2009, AWAC was given a seat in the Local Health Board.

In 2011, Baguio City won Local Government Academy-led Local Catalytic Actions for HIV and AIDS Mitigation (C.H.A.M.P.) Programme Award.

THE TELLING RESULTS

Baguio City’s initiatives from 1987 to present earned for it a number of telling results.

One, there is the undeniable rapport established from and among partner agencies to move as one in their HIV prevention efforts. The AWAC is a testament that public-private-partnership works and that the private sector can willingly take the lead. AWAC’s SEC registration is proof of the council members’ commitment to sustain the cause and offer optimum health services.

Two, given its advanced initiatives to rally the support of the entertainment sector, there has been no HIV infection recorded among regular SHC clients or from the moonlighters since the year 2000. Interestingly, the period coincided with the introduction of the annual seminar/conference series and the formation of the BANS.

Three, Bonjing offered another rallying point for all sectors of the city. Since the website was launched, it has been viewed 20,000 times. Bonjing is a continuing intervention and has even inspired a congress in November of 2012 with 500 students and school personnel in attendance.

Four, RHWC’s services is at par with private clinics at less the cost. Service referrals from private doctors is common especially since the FHI and NASPCP monitoring report was published.

Five, RHWC’s credibility enables it to generate legislative and institutional support as necessary. Such is the case with the solicitation of financial assistance for 3 infected patients as well the ordinance providing for the institutionalization of the local surveillance system. Very unique in Baguio City as well is AWAC’s membership in the Local Health Board.

Lastly, the most telling result of AWAC and HSO-SHC programs are the awards it and its members received. The SHC has been commended for being the best and most ideal. Many of its pioneering good practices have been shared by DOH to other local governments for replication. Bonjing’s APEC and DOH awards are not to be forgotten, as with the CSC conferred Pag-asa and Gantimpala awards.

MORAL OF THE STORY

Some nuggets of wisdom can be outlined from Baguio City’s experience.

Service with compassion. HSO-RHWC and AWAC values the dignity of every person. The imposition of the dress code during consultations and the enrollment of COM’s undertaking for the city’s beloveds reflect the need for the MARP to maintain their dignity. AWAC and RHWC would not have initiated this if compassion is missing. They would then not have obtained the support of BANS and the entertainers themselves if the clients felt that their concern is only feigned.

Too many chefs surprisingly improved the broth. It is critical that AWAC members are champions who will not falter until the end. It is also critical that the RHWC’s competency is without question. It would be hard to solicit external support if the internal core does not have solid foundations. The well-networked champion like Dr. Cheng and RHWC’s good reputation inspired others to join their ranks. Unlike other councils though, which wrestle with the operationalization of teamwork, AWAC members worked together by capitalizing on their strengths and filling the gaps of each other’s weaknesses. The lean RHWC staff complement mattered not since the AWAC members were willing the share the burden from the very start.

Being on guard, always. Baguio City initially thought that the HIV and AIDS threats would come from the entertainment industry. This explains for its VCT initiative and the organization of the BARS. As early as 2004 though, it shifted gear towards MSM-focused interventions because of the profile of new case reports. The introduction of bonjing is also a response to the trend towards younger infections.

Small steps to bigger gains. It has been 26 years since the local AIDS Council was first formed. Across the years various interventions and programs have been introduced, all following the PPP versus HIV approach. What is vital is that small, new, good and practicable initiatives are implemented time and

again so that team fatigue would be avoided. Small successes may translate to greater trusts, additional accomplishments to deeper commitments.

Sustainable solutions. It is not commonplace for a local AIDS council to create an identity separate from the local government. In Baguio City this is possible. AWAC also showed that PPP is a viable option even to local health service provision.

Not resting on laurels. RHWC can be considered a pioneer in a lot of good practices. This is because it did not stop seeking better ways of providing services and responding to what it recognized as the HIV and AIDS threats in the city.

Everything that happened, every engagement and commitment that RHWC and Baguio AWAC undertook for the past 26 years, led them to this state. A state of success foretold, only made possible through combined efforts, steely determination and hard work of partners. It would be a sin not to recommend that Baguio City’s RHWC be visited by all practitioners in this sector as soon as possible.

A story is told of a certain city in northern Luzon which lived the dictum -- prevention is better than cure. Unlike other towns which react instead of proactively respond to the HIV and AIDS challenge, this city solidified the efforts of its various sectors to form a coalition that furthers collaboration to address the concern. This is despite the fact that the city has no known HIV infection yet. In 2010, this place called Santiago City was granted the Emerging C.H.A.M.P. Award by the Local Government Academy.

Ironically nine months after receiving the award, their first confirmed case was recorded.

THE CITY WITH A SENSE OF URGENCY

Santiago City is a first class city in Cagayan Valley, the first in fact in the region to acquire cityhood. It is located in the Province of Isabela, about eight to ten hour drive from Metro Manila. In 2010, its population is pegged at 132,804, distributed in 37 barangays covering 27,406 hectares.

The city’s strategic geographic location makes it an investment magnet for big companies intending to gain a foothold in the regional market. It serves as a converging point for traders coming as far as Bayombong and Aparri. The economy is still based on agriculture, with corn and palay as its main produce. The commercial and shopping activity in the center is made busier by the 223 industrial establishments operating in its territory. These make it imminent that urbanization stalks just around the corner.

Home to 135 various levels of educational institutions, 13 of which offer higher education, the city can be described as an education hub as well. Seven hospitals operate in the area, with only one being public. It is thus

surprising that Santiago City does not appear to be a migration magnet, though it attracts some laborers and workers from neighboring towns.

Up until 2010, there were no registered HIV cases in Santiago City. Even with the presence of the then 32 (now 36) entertainment establishments, the city enjoyed twenty six years of zero prevalence rates since the first Philippine case was recorded in 1984. But even with zero, the city government felt that it has to ready the town in the eventuality that might come any time. Indeed, it did less than a year after.

The first positively diagnosed case was registered in 2011. By 2013, the Social Hygiene Clinic (SHC) of the City Health Office (CHO) is aware of 2 more new cases. Per National Epidemiology Center’s record though, the tally is already at 5.

UNITED WE STAND: THE COALITION FOR PREVENTION

Beginning 2008, through Executive Order (EO) 65 inked by three-termer Mayor Amelita Navarro, the local government sought to establish and strengthen a local “coalition” against HIV and AIDS. This coalition will engage in collaborative information and education campaigns aimed at preventing future infections and the possible spread of HIV and AIDS in Santiago City. Propitiously, the city became part of the beneficiaries of the Global Fund to Fight AIDS, Tuberculosis and Malaria Round 6 (GFATMR6) which should have ran from 2007 to 2012.

EO 65 which calls for the creation of the Local AIDS Council (LAC) was amended in 2009 through another EO (83) providing for the expansion of the original 18 members to 23. Among the original members are 11 local government offices like Office of the Mayor, Vice Mayor, Registrar, Social Welfare, Health and Legal ; representatives of 2 national government agencies (DepEd, PNP); and 5 civil society / private sector representatives, specifically from the Philippine Academy of Family Physicians, Santiago City Medical Society (SCMS), Isabela-Quirino Dental Society, Knight of Columbus

and SEBAS or the Santiago Entertainment Business Association. The amended EO introduced the following new members: SK Chairperson, City Local Government Operations Officer (CLGOO), media and two executive assistants (Mayor’s Office).

The EO amendment introduced the idea of an expanding membership, encouraging partnerships from the academe, business, NGOs, hospitals, professional associations and even private clinics to take part in the coalition. Never in the EOs was there a mention of a creation of a “Coalition” but the LAC members symbolically signed a Coalition Covenant sometime in 2008 and 2009 to signify their united goal of maintaining an HIV-free city.

The coalition members also fundamentally agree to participate in IEC and capacity building efforts; develop comprehensive strategic plan especially for primary health care clinic service; and ensure availability of early treatment and proper management and referrals.

Upon signing the amended EO, the CHO and the SHC did all the legwork in identifying and formally inviting additional coalition members. Many were called and many calls were made. Fortunately, GFATMR6 provided the mobilization budget to start the ball rolling.

Eventually, a beautiful spider web-like coalition came to form (see image at right). In 2010, the city government depicted that the web has 8 Insert WEB image from awards outstretched thread pillars, application document HERE (better if weaving together 3 rows of acronyms are spelled out) agency networks representing 30 offices separate from the 8 institutional pillars and with

CHO-SHC-LAC at the core.

The pillars represented by the city government, DILG-RAAT, Positive Action Foundation Philippines, Inc., DOH, DSWD-RAAT, CHD-RAAT, AIDS Society of the Philippines and the GFATMR6 strengthen and support the web. Many of the organizations at the web’s interwoven inner rows are local-based like the Nagkakaisang Kabataan ng Santiago, League of Enthusiastic Gays in Santiago City (LEGSC), SEBAS and Infant Jesus Montessori School, which boosts the inner strength of the coalition. At the web’s center is its inner strength, the CHO-SHC-LAC which provides the coordinative and secretariat services to the coalition. The competent CHO and its compact 5-member SHC accomplishes this role with a smile.

Any break in the web connection may impair the coalition. The strong linkages built on the other hand, will create a supportive environment that brings about cooperation and unity among members consistently looking at the same direction against HIV and AIDS.

NITTY-GRITTY OF THE COALITION’S MOVING CAMPAIGN

The Coalition’s membership was enriched to rally information and prevention efforts at all fronts and from all sectors. Continued vigilance is the operative word. The intent is to provide right and accurate information on STI/HIV/AIDS to the general populace and to targeted audiences to promote positive behavior especially among the population at risk, as well as increase access to HIV counseling and testing, particularly to the SHC as the referral unit.

Yearly, activities of the LAC and the coalition kicks off on May, during the AIDS candlelight memorial celebration. IEC initiatives and rounds of what the city introduced as the “mobile awareness booth” (mob-booth) would then be scheduled for the rest of the year. Normally, the mob-booth would hop from one high school or college to another. Each year ends with a highlight through the 4-5 day December World AIDS Day celebration.

Initiatives temporarily wane at the start of each year but had to start-up again in time for the Gay Pride held every March.

In this cycle of activity highs and lows, coalition members basically inform the CHO-SHC-LAC of their preferred schedule of mob-booth display in their institutional grounds, with some even providing for volunteer peer educators (e.g. from school partners) who would explain the contents of the mob-booth. Coalition partners have volunteered to shoulder the reproduction of some of the IEC materials like posters, tarpaulins and fliers.

The local government through the CHO and SHC remains as the coalition’s focal institution for capacity building on HIV and AIDS. At times, sponsoring NGOs and private sector partners share some financial support for the conduct of training activities. The city government endeavors to mainstream HIV/AIDS response initiatives through its other services like the HIV 101 to pregnant mothers, joint activities with the local blood council and mandatory vaginal smearing.

Since the coalition is primarily formed to raise Santiagueños level of awareness, much thinking went on the contents of the education campaign materials and the presentation approach. The LAC members scoured for available online materials to carefully design their IEC materials. They then decided to put all the information in an easily movable but engaging platform. This is how the mobile awareness booth (referred here as mob- booth) came to life.

As the name implies, mob-booth is an easily transferrable two-dimensional poster display booth that stays for 1 to 3 days in one designated location at a time. It always comes with a package of 2 to 4 volunteer peer educators who are adept in deepening the understanding of bystanders and reading/listening audience on the nature, preventive actions for, voluntary testing and referral services for HIV and AIDS. These peer educators are required to attend a 3-day course before they could be certified as such.

Mob-booth is usually displayed in schools, thickly populated areas like market and bus stations and in community meet-up areas. Oftentimes, school displays ran parallel with organized lectures or workshops for secondary and tertiary students on HIV and AIDS. The apparent strategy to target schools with information on HIV and AIDS stems from the Coalition’s acceptance that the youth, as young as secondary students are nowadays experimenting with risky behaviors.

For mob-booth displays at more public places like markets and terminals, peer educators mainly come from the ranks of the SEBAS and LEGSC. They are therefore mostly establishment entertainment workers (EEWs) and/or men having sex with men (MSM), who can better relate with their peers and potential partners the dangers of engaging in risky sexual behavior. This is complemented by weekly lectures to EEWs and their weekly vaginal smearing, condom distribution and offer of participation in city government-led livelihood programs.

As part of the May 2009 candlelight memorial, the coalition launched a signature campaign that aimed to collect 10,000 signatures of Santiago City residents to get their support and involvement in the cause. Santiago City responded and they hit the 10,000 signature target.

SMALL GAINS

A program can only be truly measured through its results. How has the coalition and its moving campaign strengthened the local HIV and AIDS response in Santiago City?

One, partnerships and networks have been established and maintained. Non-government coalition members are still willing to share or invest if you may, on the reproduction of the IEC materials. Participation of coalition members on key annual events (May; December) remains high. Requests for the mob-booth from schools like Patria Sable Corpus College, Southern Isabel College of Arts and Trade, North Eastern College of Nursing and

private sector partners have continued and even intensified. The working relationship in the coalition has reached a healthy state where service/client referrals is now possible. Meaning, some EEWs clients have been referred to private dermatologists for complementary skin services.

Two, magnitude of population reached. The ‘Be Counted to the 10,000’ signature campaign is proof that the IEC has reached close to a tenth of the city’s population. More importantly, the strategic targeting scheme required that ‘vulnerable younger’ residents are the audience of the mob- booth. It therefore comes as no surprise that the P50,000 award money from the Local Government Academy was used to further reach more of the populace. The CHO in 2011 conducted 4 batches of courses for BHWs and even barangay captains and council representatives not only to deepen their knowledge on HIV and AIDS but also to recruit possible partner advocates at the community level. They used the remaining amount for a 1 day seminar-workshop for 45 youth student government leaders and school guidance counselors with the hope of developing a cadre of advocates for the fight against STI/HIV/AIDS and drafting key youth leaders in organizing HIV/AIDS youth councils.

Three, Dr. Genaro Manalo of the CHO successfully facilitated the formation and induction of the first set of officials of the HIV Youth Council in October 2011, representing 8 school of government presidents who themselves formulated their council action plan.

FOR MANY ARE CALLED, AND MANY WERE CHOSEN.

The Santiago City local HIV and AIDS response is a good case in networking and coalition building. It may have benefitted from the presence of the GFATMR6 then, the continued functional existence of the coalition now is proof that it works. There may remain a couple of challenges such as on changing of the guards, improving the mob-booth, better targeting of audience, profiling the vulnerable, maintaining a big pool of volunteer (honoraria-based) peer educators and convincing catholic schools to

partner with the IEC, but there are 3 major lessons that only the Santiago City experience can impart.

The value of foresight. Even when the coalition is yet unaware from where specifically their HIV/AIDS challenge lies, they are united in their belief that prevention is the best solution. And prevention is only possible if the community is informed and educated. The coalition thus applied the country scenario and designed IEC strategies that cater to the 15-29 age bracket who comprise at least 20% of the city’s population. They decided to bring the HIV and AIDS message to the schools.

Knowing as well the growing MSM trend in the Philippines, the city government hopes to initiate an MSM friendly clinic and expand the access to VCT by putting up a clinic in the public market area. To further lessen the infection threats among EEWs, CHO feels that provision for alternative livelihood projects for them should continue to be included in the annual city budget.

Follow the Herd. The idea of putting up the mob-booth in densely populated areas in the city and raising a huge number of signatures is a good way to make noise for the HIV and AIDS campaign and make the populace notice the cause at the same time. Indeed the coalition is right in thinking that if the people do not come to you, you can always go to them.

Hold Hands. Due to the numerous requirements of Philippine laws on local governments to create such and such councils, it is normal for LGUs to just form the council and expect a lackluster performance. This is as pronounced in the case of the creation of LACs since HIV and AIDS is not viewed even by hotspot cities as an urgent problem they are ready to deal with. Santiago City is thus noteworthy since even with just an Executive Order and the zealous efforts of the CHO-SHC and the coalition partners, they have made gains in increasing the level of awareness of their populace on the concern.

Though the coalition members do not meet as frequently, the active participation and strong support is evident. They may have to learn more about direction setting, planning, institution building and local legislation so they can properly formalize their coalition through an ordinance.

Santiago City can no longer return to the time when they were still ‘zero’ but they can surely do something to ensure that the present figure (5) no longer increases. Deviating from the biblical words that follow the phrase “for many are called”, in Santiago City, many were chosen. These chosen ones, working together, will make that possible.

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Adolescence is characterized by adventure and curiosity. For Alexis Sarza and a group of friends, their curiosity about a youth outreach program which offered an out-of-town five-day seminar would take them on the path away from alcohol, drugs, sex and crime and into a life of rescuing teenagers from risky behaviour that will adversely affect their future.

Local government best practices and development plans have been known to incorporate standards like child-friendliness or business-friendliness. It is less familiar for local governments to strive towards being adolescent- friendly. Adolescence is a stage in a child’s life where self-discovery, independence, and individual personality are important developmental issues. Adolescence is a period of transformation and adventure which also provides a wide opportunity for exposure to risky behaviour like vices, sexual activity, and even social deviance. Whether a child successfully transitions to adulthood largely depends on the adolescent’s family situation and dynamics, the realities and stimuli in the immediate social environment and access to support systems (government or non- government).

The City Government of Parañaque in partnership with civil society, especially a self-help organization of at-risk teenagers, set out to provide a more adolescent-friendly community for all teenagers. Their strategy would involve even the most unlikely ally and open up opportunities for the city’s youth to lead peers in living safer lives towards adulthood.

PARAÑAQUE CITY

Parañaque is one of the cities of Metro Manila (National Capital Region) and is the first city that welcomes travellers who come through the Ninoy Aquino International Airport. It is located in the southern part of the region

and bounded by Pasay and Taguig to the north and by Las Piñas and Muntinlupa to the south. It is the sixth most populous city in Metro Manila with a population of 586,322. Nineteen percent of the population is between the ages of 10 to 19.

The city is mainly residential. It is where the country’s largest subdivision is located. There are commercial and industrial activities along the South Superhighway and major thoroughfares like Sucat Road/Dr. A. Santos Avenue. The entertainment belt along Roxas Boulevard in Manila and Pasay peters off on the stretch around Paranaque. There are also informal settlements located around the residential developments and the commercial corridors.

While Paranaque does not belong to the top 10 hotspots of HIV infection, it is very close to hotspots like Manila and Pasay City. With the high mobility within in Metro Manila, STI and HIV infections cannot be limited by political boundaries.

BALUTI PROGRAM

Parañaque, together with Las Piñas and Taguig, is a pioneer of the Adolescent Friendly Reproductive Health Services (AFRHS) Network in the Philippines. AFRHS is an international network lodged at the Department of Health which in turn had developed national standards on health services for adolescents. The standards include making basic health services accessible to adolescents, reduce teenage pregnancies and its complications and reduce STI infections and its effects. There are also interventions to reduce risky behaviour among adolescents like substance abuse, violence, injury and mental health. Local health stations are the principal implementers of this program while NGO partners are involved mainly in capacity building.

Save the Children is an international network of NGOs which support and implement programs that enable young people to adopt healthy attitudes and behaviour regarding their health and development. In 2003, it reached

out to a group of teenagers in Barangay San Dionisio who were into risky behaviour like substance abuse, drug pushing, and sexual promiscuity. These 12 young people were invited to a 10-day out-of-town seminar. Their motivation was just to have a change of scenery as one of their youthful adventures. These twelve would eventually realize that they are being offered the opportunity to change the course of their future.

The twelve trainees established BALUTI or Batang Laging Umiiwas sa Tiyak na Impeksyon as a youth peer support group with Alexis Sarza as its first president. The acronym also means “shield or armor” in Filipino— reassuring the protective nature of the organization. BALUTI set out to address early sexual debut, teen-age pregnancy, risky sexual practices, sexually transmitted infections, HIV and AIDS. The organization uses various strategies such as peer education, film showing, one-on-one counseling, provision of free condoms, voluntary counseling and testing, and facilitating community support for HIV and AIDS. A BALUTI outreach is conducted with precise procedure but with a lot of first hand points of view from peer counselors who were themselves at-risk teenagers. Since BALUTI’s outreach aims to proactively affect the behaviour of at-risk youth, they monitor the change in reproductive health attitudes and behaviour of each batch of kids taken into its program.

BALUTI has a two-pronged approach to peer education. They both reach out to youth in the community as well as youth in the schools. The peer educators plan for interventions every six months. Youth who are taken into the program within this period are considered as a batch. Target communities are chosen due to severe poverty in the area (depressed communities), a large youth population, and a large number of most at-risk population (MARPs).

The BALUTI program has two levels. BALUTI Part I is a training program that focuses on strategies for the general population of adolescents. This includes topics on the UN Convention on the Rights of the Child, sexuality, life skills and since 2010, also a spirituality module which is conducted by speakers from the Parish of St. Andrew. This is normally a three-day

seminar-workshop. It is from Part I that the BALUTI peer educators can scout for new peer educators who they can recruit to join their ranks. Particularly for the outreach to MARPS in communities, one would likely be invited to be a peer educator if he or she exhibited interest on BALUTI activities; also a youth at-risk; and someone who exhibits leadership skills. That is why some peer educators used to be gang leaders. On the other hand, school-based peer educators tend to be sophomores or juniors, as they still have more time to spend in school.

BALUTI Part II focuses on interventions for adolescents at-risk. This part uses the “Give Me Five Communication Approach.” This covers five core topics on substance abuse, teenage pregnancy, STI and HIV/AIDS, safer sex, and voluntary counselling and confidential testing. This also involves five action statements asked by peer counsellors in small group discussions or even on a one-on-one basis which enables the participants to reflect on the topics discussed. The five action statements are:

1. Kumusta ka? (How are you?) 2. Alam mo ba? (Do you know?) 3. Ganito kasi yun (It’s actually like this…) 4. Ano sa tingin mo? (What do you think?) 5. Kita tayo ulit (Let’s meet again)

Part II normally takes two days. Afterwards, peer educators conduct monitoring and reinforcement of positive behaviour through one-on-one counselling, regular house visits and the use of a diary. The peer counsellors would check the diaries at least once a week to ensure that the participants are recording their behaviour.

Typically, even before the two-stages, peer counsellors and some participants would undertake a “reality mapping” of their area. It is composed of two workshops. Workshop 1, the at-risk adolescents are asked what risky behaviour they have as well as the reasons for engaging or not-engaging in these risky behaviours. Workshop 2 involves identification of hotspots in the community map where these risky behaviour occur.

The program also seeks to have the communities provide a supportive environment for the at-risk adolescents to reform themselves. The results of the reality mapping are presented to barangay and homeowners’ association officials for appropriate action. Parents in the target areas are also organized and undergo a three-day training on children’s rights, technical support from health authorities, as well as dealing with their children’s risky behaviour and being good role models.

FROM BASELINES TO VOLUNTEERS

In 2004, with support from the City Government of Parañaque, Save the Children and Lunduyan Foundation, 50 peer educators were trained. They focused on four sitios of Barangay San Dionisio working among gang members, drug users, out of school youth and youth in prostitution. Currently, BALUTI is operating in five adjacent barangays (San Dionisio, Baclaran, San Isidro, Sto. Niño and La Huerta) and in five schools: Parañaque National High School (PNHS), Baclaran High School, PNHS-La Huerta Annex, Don Galo High School and St. Andrew’s Parish Alternative Learning School.With additional support from the city government, BALUTI was able to expand training for peer educators to six more barangays: San Martin, Merville, Sun Valley, Moonwalk, BF Homes, and Vitalez. Peer educators there have also set-up similar self-help organizations. The World Health Organization and the AFRHS Network also invited BALUTI peer educators to train new peer educators in the cities of Caloocan, Malabon, Navotas and Valenzuela. With UNICEF’s support through funding and workshops, BALUTI was able to use “The Power of You” video during school and community outreach. From 2008 to 2012, BALUTI activities have been supported by the MTV Staying Alive Foundation.

Shocking Back Stories to the Baselines

Each time an adolescent is admitted into the BALUTI program, he or she is asked to accomplish two forms that serve as part of the baseline data for their batch: the Adolescent Health Assessment Form and the BALUTI Intake Form. The baseline survey points to smoking, alcohol drinking, drug use and

pre-marital sex as the main risky behaviour that adolescents engage in. Gang wars, gambling and watching pornographic films are also constantly identified. These may no longer be surprising realities in urban life. However, according to Dr. Ma. Dolores Matias, BALUTI Mentor and doctor at the San Dionisio Health Station, the stories behind these risky behaviour tend to be more shocking realities. She recalled that one girl repeatedly gave sexual favors to have coffee. She clarified that this was not expensive coffee from famous coffee chains, but just plain instant coffee. Data from the schools seemed more disturbing as there was one class that had half of its students absent in one afternoon. Apparently, the absent students had “bookings” as sex workers.

In one reality mapping exercise, the clean streets of a private subdivision belie the drug use of some of its teenage residents. With the procedure of reality mapping the peer educators were able to identify that there is a particular roof top which is used for drug use sessions. Outputs from reality mapping workshops are also presented by BALUTI to barangay officials and homeowners’ association officers for their appropriate action. Even Msgr. Manuel Gabriel, the former parish priest of St. Andrews, commends BALUTI’s reality mapping outputs as an ingenious way of knowing the community. The parish would eventually craft and jointly implement the Spirituality Module for BALUTI Part I in 2010.

Volunteerism and indigenous development

BALUTI remains a volunteer organization. Its peer educators stay in posts at health stations and have a permanent working room at the San Dionisio health station. They are available for counseling or any health related assistance that adolescents may need. Their presence in the health stations reassures teenagers that there are peers in government health facilities who will help them navigate the health services. This also makes health services less intimidating compared to a system where they have to deal with adults first. STI and HIV testing and even condom distribution is no longer awkward. BALUTI also involves the youth under its programs in community projects like community cleaning as part of an effort to reach

out to the community which often considers at-risk youth as nuisance. With the help of the internet, peer educators continue to incorporate new tools that will help them better communicate the aims of BALUTI. Some BALUTI- trained peer educators who have formed separate organizations have been involved in advocacies for reproductive health and other adolescent issues.

BALUTI’S SUCCESSES

From 2008 to 2012, BALUTI has reached 68,883 adolescents of Parañaque. The end-line surveys and the monitoring (home visit and one-on-one counseling) conducted towards the end of each intervention shows significant results in behaviour modification. The consolidated data point to a 138% increase in protected sex. There even seems to be a high incidence of abstinence. Gang fights were reduced by 96% and drug use by 87%. There was a 77% reduction in gambling, 68% in smoking and 61% in alcohol drinking.

These results did not go unnoticed. In 2009, the Paranaque City Government was awarded the Gawad Galing Pook for its adolescent- friendly health services much of which could be attributed to the initiatives of BALUTI in cooperation with the LGU. In 2010, Paranaque and BALUTI were given the CHAMP Award (Catalytic HIV and AIDS Mitigation Program). This gave more prominence and attributed successes directly to BALUTI’s response to STI and HIV/AIDS by proactively addressing risky behaviour and building life-skills.

With the spotlight on its successes, BALUTI peer educators have become an important resource for the outreach to teenagers on preventing HIV/AIDS infections in the Philippines. BALUTI provides a speaker’s pool for the AFRHS network which has taken some peer educators to trainings for AFRHS implementers from Borongan, Eastern Samar; Tandag City, Surigaodel Sur; Mountain Province and Ifugao; and Manila. Some BALUTI peer educators also spoke at an AFRHS network conference in India. They have also participated in the public consultations on the Implementing

Rules and Regulations of R.A. 10354 or the Reproductive Health Law and the RH and Sexual Education program.

LEARNING FROM THE YOUNG

BALUTI has been engaged in an urban warfare against HIV/AIDS. Their strategy is “winning the hearts and minds of adolescents” for them to leave their risky behaviour and be more conscious of their health. The BALUTI formula relies on the peer educator and his/her convincing power. Being a former adolescent practicing risky behaviour, the BALUTI peer educator has “street credibility” who can show a teenager that it is possible to change for the better. A peer educator in this sense, is not just someone who comes from the same age cohort, but is someone who has experienced risky behaviour and can empathize with the emotional, social and family issues. The BALUTI peer educator is a relatable person, but also someone who cannot be easily fooled by manipulation or ruses. The “delinquents-to-role models” approach has proven effective as the data showed that significant behavioural changes were observed. In the baseline data, a reason common to all risky behaviour was “peer pressure.” In this sense, this is peer education versus peer pressure, with peer education winning.

Having a first person point of view, BALUTI counselors also devised ways to battle with the stigma on at-risk adolescents. The choice of the term “baby colognes” instead of a rather technical and impersonal “MARPs” shows this concern for addressing that stigma. Baby colognes imply that these teenagers need “tender loving care” which was a tag-line in a cologne’s TV commercial. Forming the support mechanisms within the community is also very important as the baby colognes make the difficult transition back to healthy living. The capacity building for the Parent Adolescent Lifeline also enables parents to sufficiently respond to the needs of their children. Even the Church’s acceptance of and participation in the project, lends a lot of credibility to BALUTI. In a certain sense, the stigma is wearing off with the election of six BALUTI members during the most recent Sangguniang Kabataan elections.

Volunteerism has both its advantages and pitfalls. While BALUTI relies on the energy and commitment of its volunteers, there are other factors that impede the volunteers’ full participation in the program. Peer educators/facilitators who are still in school are unable to join some activities of BALUTI. Volunteers have to balance personal/family life with work or study as well as volunteer work.

It truly takes a village to raise a child. Adolescence is not the end of childhood, it is its culmination and the crucial transition to a healthy and meaningful adult life. For BALUTI pioneer, Alexis Sarza the AFRHS outreach made him feel that someone trusted him again. He and his friends set out to save the youth on which society has almost given up and transform them as very relatable role models. It is this same empowerment that BALUTI wants to impart to at-risk adolescents in Parañaque and beyond.

Port cities are one of the most vulnerable to exposure to HIV infections because of the high traffic of arriving and transiting humans. Risky behaviour between transients and the local population provide a ripe situation for the spread of anything contagious or infectious. While the Philippines admittedly has very porous borders, Zamboanga holds a unique situation as the only major urban center that is close to the country’s only near-land border. This makes it an important city in the Philippines’ quest for economic integration with the rest of Southeast Asia. This also makes it the Philippines’ backdoor, which adds more complex variables to its nature as a port city.

Every city has its own red light district. Whether sex is being traded in its entertainment establishments, it has always been a cat-and-mouse game between law enforcement and the sex traders. While local governments are expected to enforce laws against prostitution they also have to look after the over-all health status of the population in its jurisdiction. This is thin line that implementers of local HIV/AIDS response have to walk in order to protect everybody in the city—transient, refugee or local.

Local governments hardly play any role in defending the nation’s borders. However, HIV/AIDS do not know any international borders. Local governments like Zamboanga face the challenge of a global epidemic with local strategies and local means while facing the realities of a shrinking and highly globalized world.

ZAMBOANGA’S CHALLENGE

Zamboanga is a highly urbanized city located at the south-western part of the Philippines. It is the Philippines’ sixth most populous city and the third largest in terms of land area. Its total population in 2010 is 859,595 living in

1,483.4 square kilometres of land. Thirty of its barangays are urban and 68 are rural—10 of which are island barangays.

Zamboanga City is bordered by the territories of the provinces of Zamboanga del Norte and Zamboanga Sibugay to the north and Basilan to the south. The city is also located on a narrow channel that connects the Moro Gulf and the West Philippine Sea (South China Sea). Zamboanga is the Philippine’s main urban center for the Brunei-Indonesia-Malaysia- Philippines East Asia Growth Area (BIMP-EAGA). Zamboanga is considered the “backdoor of the Philippines” as this is the main transit point to Southeast Asia after Manila. Migrants (legal or undocumented) often enter Zamboanga as they island hop through the Sulu archipelago into Malaysia. Zamboanga is also the reception area for deported Filipino workers from Malaysia’s Sabah state. The city also lies at the cultural boundaries of Christians and Muslims in Mindanao. Christians comprise 73% of the population while around 27% are mainly Muslim and from other faiths. Zamboanga City is also the regional education centerof Region IX – Zamboanga Peninsula (including the BASULTA sub-region of the Autonomous Region in Muslim Mindanao). This increases the youth migrant population as college-age cohorts flock to the city for tertiary education.

Furthermore, there are three large military installations in the city: the Southern Command, Edwin Andrews Air Base and the Naval Station Romulo Espaldon. Zamboanga is also host to American troops participating in the Balikatan exercises under the Visiting Forces Agreement. Military installations tend to attract multiple sexual partner practices of uniformed personnel who often go off-base for recreation purposes.

Its geographic location close to neighboring countries with high HIV infections, the region’s porous borders and the high transient population combine to increase the city’s vulnerability to exposure. In fact, the first two cases of HIV infection was detected from two Filipino immigrants returning from Malaysia.

Being a highly urbanized city, Zamboanga has its sizeable number of adult entertainment establishments which become hotspots for possible infection. Because of these hotspots, high risk groups can be found in these establishments most especially male and female sex workers and clients of sex workers. However, the most at risk section of society are the “Men having sex with men” (MSM) which comprise 73% of HIV cases in the city. Seventy percent (70%) of infections happen among those aged below 35.

THE PARTNERSHIP PROGRAM

In 1996, Zamboanga City was chosen by DOH as one of the sentinel sites in the Philippines for the USAID’s HIV surveillance project. After some surveillance in the interim years, the “Effective Partnership for an AIDS-Free Zamboanga was begun by the City Health Office (CHO) of Zamboanga City during the term of former Mayor Maria Clara Lobregat and the Human Development and Empowerment Services (HDES), an NGO.

Established in 1998, HDES is the Zamboanga implementer of USAID- supported health projects focusing on high risk groups (i.e. female sex workers, men having sex with men, male and female sex workers, customers and injecting drug users). It began with a community outreach and peer counselling program for street children and urban working children. HDES covered most of the HIV prevention component which included conducting lectures, learning sessions, information and education campaigns, etc. On the other hand, the CHO took charge of behavioural surveillance and testing. The organization also implemented components on Barangay Legal Action Against Child Prostitution (BLAACP) which paved the way for the creation of Barangay AIDS Councils in 10 barangays. This became the impetus for the establishment of the Zamboanga City Multi- Sectoral AIDS Council (ZCMSAC). Being the only active NGO on the issue of HIV/AIDS, HDES became the NGO representative in the ZCMSAC.

The program aims to (1) heighten the awareness and knowledge on STI- HIV/AIDS through IEC and advocacy; (2) intensify disease detection, early

diagnosis, treatment, counselling and referral; (3) develop responsive local policies, plans and programs to help prevent the spread of STI-HIV/AIDS; (4) conduct surveillance of target groups; and (5) strengthen linkages between different sectors and continue to seek additional resources.

ZCMSAC AT WORK

Formalizing the multi-sectoral approach. The HIV-AIDS response in Zamboanga City began as a collaborative program between the city government and a specialized NGO. However, HDES also pushed for a multi-sectoral approach by involving more stakeholders by establishing the Zamboanga City Multi-Sectoral AIDS Council (ZCMSAC).

The ZCMSAC was created under City Ordinance 234. The members include the City Mayor (or his/her representative as chair); Chair of the City Council’s Committee on Health and Sanitation Committee and Committee on Women and Family Welfare; and representatives from various sectors (Government; NGOs; Civic clubs; Education; Media; Medical Profession; Youth; Business and labor; Gay; and Religious sector).

Among the members of the ZCMSAC include representatives from the Zamboanga Entertainment Association (ZEA)—later named as the Association of Partners for an AIDS-Free Zamboanga or APAFZ. ZEA or APAFZ is the umbrella organization of entertainments establishments in the city. Members include individual proprietors of entertainment stalls as well as members from the 22 KTVs from the Shindig Stall Owners’ Association and 15 KTVs from the Parklane Plaza Stall Owners’ Association. In 2001, this sector only had one representative in the council. Starting 2003 there have been two or three representatives who sit in the council.

The cooperation from these entertainment business owners is key to preventing infections in one of the hotspots of sexual contact. Owners, managers and entertainers are required by ordinance to attend accredited seminars on STI/HIV/AIDS every six months. The permit/license to operate

is tied to this requirement and no establishment will be allowed to operate without the verification of compliance to this requirement. Each establishment is further required to have at least one trained peer educator and register entertainers and employees under its employ at the CHO. The ordinance also pushes for the 100% use of condoms and mandates weekly medical examinations of entertainers and others in similar occupations.The ordinance also enumerates prohibited acts in entertainments establishments (Article IV) which includes prostitution, exclusive spaces, lewd shows, child labor, and trafficking.

Clear complementarity. Junpicar Daluz, former Project Manager at HDES, said that the City Government of Zamboanga acknowledges the complementary role of HDES in responding to STI/HIV/AIDS. While the local government is focused on implementing the provisions of City Ordinance 234, HDES continued to work on its projects while working with the LGU and ZCMSAC. From January 2006 to October 2007, HDES implemented donor-funded projects that targeted high risk groups, injecting drug users (IDU), and street and urban working children. HDES also played key roles in crafting IEC/advocacy materials and activities which included versions in Chavacano which were distributed to target populations, entertainment establishment owners and the general public (through the barangay health centers). HDES’ main role in the program is training peer educators through the Indigenous Leader and Outreach Model. Peer educators are members of at-risk populations who can empathize with peers and also help as models of reformed behaviour that leads to preventive health practices. HDES and the CHO both operate outreach centers in the entertainment districts. The spaces were provided by the ZEA/APAFZ.

According to Dr. Kibtiya Uddin, Physician at the Zamboanga City Reproductive Health and Wellness Center, HDES was crucial in reaching out to injecting drug users (IDUs). This group perceived the City Health Office as a spy for law enforcement which impeded the CHO to directly engage them. HDES stepped in through its peer educators and was eventually able to teach IDUs how to avoid infection through sharing of needles.

As a consequence, the City Health Office’s resources were geared towards more resource-intensive, free laboratory testing and analysis, STI treatment, monitoring and evaluation, and the maintenance of outreach posts (including maintenance of facilities and salaries of employees).

Acting together, the LGU has involved HDES as a member of ZCMSAC’s monitoring, surveillance and rescue arm, “Task Force Buenas”—a body that conducts inspections of all night spots to monitor the compliance of the necessary business permits, sanitary and health laws, and safety and security measures under the Building Code and other relevant laws and ordinances. The inspection team is composed of the City Administrator (Chair), City Health Officer (Vice Chair), and the City Treasurer’s Office, City Police Office and HDES as members. The CHO issues a “Pink Card” which reflects the history of a sex worker’s mandatory weekly health checks. HDES is also a member of another team of Task Force Buenas that conducts rescue operations for minors employed in entertainment establishments, testing for registered female sex workers and freelance sex workers. This group is composed of the CHO’s Social Hygiene Clinic, Commission on Human Rights and the city’s City Police Office, and Social Welfare and Development Office.

APAFZ’s duties were clear and simple. They were expected to constantly remind members of the LGU’s policy. Establishments were reminded to comply with three main policies: (1) no minors working in the establishment; (2) condoms should be available in the establishment; and (3) no infected worker should be on duty. Violation of any these three may lead to the closure of the establishment. Having an umbrella organization do the legwork of the advocacy, enables the LGU to focus on enforcement and treatment.

Organizing at-risk groups. Several organizations were organized since the program began. These organizations were the conduits for projects that are specific to the needs of their particular group. Aside from ZEA/APAFZ, among those organized were the:

1. Barangay Council for the Protection of Children – aims to help combat child prostitution, child trafficking, and STI/HIV-AIDS infection 2. Asosasyon ng mga Batang Lansangan sa Zamboanga – an association of sexually exploited street children under sixteen 3. Asosacion de las Estrellas de Zamboanga – a group from the gay sector which produced the “Gay batu?” localized IEC support material. 4. Mariposa de Zamboanga – a group of gay, bisexual and transgendered who conduct school advocacy activities and a beauty contest, “Ms. Mariposa,” as part of the ZCMSAC’s advocacy program for MSMs. 5. Shindig Stall Owners Association (SSOA) – later integrated with ZEA to form APAFZ. 6. Vida Vivo Zamboanga – support group of Persons Living with HIV

Targeted interventions included the organization of the annual Señorito y Señorita de Salud as part of activities for World AIDS Day. Participants come from different colleges and universities in Zamboanga. In 2010, 500 social media users were on-board an online group that leads the cause for “Take the Test, Take Control (HIV).”

OPENING DOORS TO GOOD PRACTICES

Surveillance database. Since the detection of the first HIV infections in the city in 1995, data on HIV infections in Zamboanga became more accurate with the establishment of ZCMSAC. From 2003 to 2013, the Reproductive Health and Wellness Center or RHWC (formerly called the Social Hygiene Clinic) had registered 68 new infections at an increasing rate. According to Dr. Uddin, this may be attributed to more at-risk people coming for testing and better detection due to close monitoring. The analysis of the registry points to the most at-risk sector in the city.

HIV Cases by Client Groups No. % Men having Sex with Men (MSM) 51 72.9 Client of Sex Worker (CLSW) 5 7.1 Female Sex Worker (FSW) 3 4.3 Partner of Injecting Drug User (IDU) 1 1.4 Others 10 14.3 Total 70 100

Number of Cases by Age (at time of diagnosis) No. % 15-24 24 34 25-34 25 36 35-44 19 27 45-54 2 3 Total 70 100 Source: RHWC, City Government of Zamboanga (2013)

Forty-four (44) of those infected were residents of Zamboanga City while 26 were transients. Twenty-five (25) cases are returning migrants (17 of which came from Malaysia). Unfortunately, 16 cases ended in 16 AIDS deaths.

In general, there is less than one percent HIV prevalence among MARPs and the general population. Among MSM the HIV prevalence is at 1.33%. STI prevalence is at 12%.

Enforcement. Task Force Buenas has recommended the closure of at least 17 entertainment establishments which were caught violating provisions of City Ordinance 234. Beginning in 2006, the task force’s operations rescued the following number of persons. Year Number of Sector rescued persons 2006 140 Sex workers 5 Trafficked women and minors 2007 41 Female sex workers and MSM 2009 9 Minors from videoke bars Source: RHWC, City Government of Zamboanga

Awards and recognitions. Probably the highest recognitions that the City Government of Zamboanga has received are from the Gawad GalingPook (GGP) Foundation. In 2005, the “Effective Partnership towards an AIDS-Free Zamboanga City” was given the GGP’s Trailblazers Award. The following year it was given a Special Citation on Local Capacity Innovations for the Millenium Development Goals #6: Combat HIV/AIDS. These recognitions have paved the way for the city government to access donor funding like the USAID’s Health Governance Project, UNICEF project for prevention of STI/HIV-AIDS infection for pregnant women and children, and the Global Fund Rounds 5 and 6 for MARPs, migrant workers and Persons Living with HIV (PLHIV). In 2010, the DILG awarded Zamboanga City with the HIV CHAMP Award.

The city government has hosted delegations from other local governments as well as international groups from Thailand, Sri Lanka, Iran, Indonesia and Malaysia who would like to learn from their experience.

Continuing challenges to implementation. According to the CHO, there are hard to reach at-risk groups—specifically freelance sex workers (FSWs). The program is able to reach out to FSWs in the streets but FSWs in schools are hard to reach. The solution was to conduct IEC/advocacy activities in schools. However, direct contact may be hard to come by as voluntary disclosure of their status as an FSW may not happen while the outreach personnel are still in campus. In addition, closeted gays are also difficult to reach. While closeted peer educators have been trained, engagement depends largely on an awkward secret disclosure that one is gay.

Dr. Uddin adds that the protocols for sex workers in Zamboanga tend to drive sex workers who lack documentation (as simple as birth certificates which are required before registering at the CHO-RHWC), to leave Zamboanga for a third location. Because such a sex worker has not been profiled or checked by the CHO for infection, their mobility may aid in spreading STI/HIV/AIDS to neighboring provinces.

The returning migrant workers and deportations from Sabah, Malaysia still pose a threat that the LGU can address only at a limited scale. Many of the returnees are local residents and easily integrate back to city life. The ZCMSAC has no control over preventive action, or the lack thereof, in Malaysia.

Finally, because the program also relies on non-government initiatives and actions, the nature of HDES’ project-based funding poses a slightly annoying disruption of HDES’ services. However, the city government is more than willing to adopt HDES’ peer counselors as voluntary health workers during periods of funding gaps.

LESSONS FROM THE BACKDOOR

Champions are key. The Zamboanga City Government had to come to terms with the fact that it was one of the 11 most at-risk cities in the Philippines. The confluence of realities pointed to the need to respond to the problem of HIV/AIDS from abroad which puts the local population at risk. The detection of the first two cases from Malaysia yanked the city government to act with some persistent prodding from a non-government organization.

Since Mayor, Maria Clara Lobregat began the program, her successors Celso Lobregat and Isabel Climaco have fully supported the anti-STI/HIV/AIDS activities in the city. Incumbent Mayor Climaco began as the program’s champion during her term as city councilor. HDES’ lobbying for formal intervention from the local government paved the way for policies and strategies that have institutionalized the roles and expectations from the various sectors in jointly combating STI/HIV/AIDS. While the CHO and ZCMSAC will remain as permanent champions for the program, they are continuously building champions from among the at-risk groups.

Navigating moral and legal dilemmas. Prostitution remains illegal in the Philippines. However, local governments and local health policy has to

tread carefully between acknowledging the reality that legal business establishments (entertainment stalls, massage parlors, even movie theaters) hosts sex workers and risky sexual encounters and the fact that a sexual profession cannot be given any legal recognition. Conditions on sexual protocols imposed on business establishments acknowledge a de facto existence of sex-for-pay in these establishments. But in an effort to stop a more urgent problem of an HIV epidemic, law enforcement gives way to the practicalities of a public health intervention. Moreover, even religious leaders come to an accommodation of these interventions in order to stem the spread of a disease. Catholic, Christian and Muslim representatives sit in the ZCMSAC and lead ecumenical prayers during World AIDS Day activities.

Sharing the legwork. The PNAC template for HIV/AIDS response includes a multi-sectoral approach through the establishment of a local AIDS council. However, as an additional special body, the LAC may be doomed to suffer a similar fate as other local special bodies—officially constituted but hardly functional. Operating by committee is always a challenging task because one has to manage the different perspectives on tackling a problem even if members are all like-minded or are driven by a singular cause. In the case of Zamboanga, the CHO and other LGU departments gave the NGO and community partners a bigger role in reaching out to at-risk groups for the preventative component of the program. Because the LGU is still considered as a law enforcer, the non-government partners were able to engage the target groups and pave the way for government to reach out.

Faced with a daunting task of HIV/AIDS infection that has an international dimension, the multi-sectoral approach employed by Zamboanga City offers a model that emphasizes complementarity not only in planned situations but also in situations that arise from unexpected circumstances like engaging hard to reach at-risk groups or providing stable funding or resources. This enabled the efficient use of scarce resources which led to the promising achievements so far. The continued expansion of the

network of peer educators and the organizing at-risk groups ensures a wide base for institutional memory and develops a new set of champions who can continue to advocate for more responsive policies and interventions as well as provide a pool of collaborators and community mobilizers.

All good managers are familiar with the story of anybody, everybody, somebody and nobody. As the story implies, if everybody could do it, most of the time nobody does it. This fortunately does not apply in the case of the Province of Aklan. In Aklan, it is everybody’s business. Everybody worked to respond to the growing threat of HIV and AIDS in the locality.

AKLAN, TOURISM, HIV AND AIDS

Aklan, a province with about half million population (2010), is the heart of tourism in Western Visayas. It is composed of 17 municipalities with Kalibo as its capital. It is best known for Boracay Island, with its world renowned 7 kilometer white sand beach. In 2012 alone, it welcomed in its shores more than 1.2 million tourists, earning for it Php 26 billion in receipts. For the past twelve years, the average annual growth rate of tourist arrivals is at a minimum 15%.

It was in 2001 when the province learned about the first recorded case of an Aklanon infected with HIV/AIDS. In the span of 13 years, there have been 36 registered cases, 8 of whom have passed on. Compared with the numbers for the region, Aklan’s cases represent only about 11% of the Western Visayas total. But the stealthy and undeniable sex trade concealed in the entertainment establishments and the changing lifestyle choices of homosexual members of the community, makes the province a hotspot for HIV and AIDS.

The virus transmission is primarily thru sexual activity. Some are from men having sex with men (MSM), others from those practicing multi-partner sex or even ‘trip’ sex. Some infections originated from OFWs.

Areas in the province with a busy night life are considered the critical spots. More or less these are in 3 municipalities where the number of night establishments is maintained, if not on the rise. These are in Kalibo, Malay and Nabas.

If the rate of STI infections were to be the measure of the eventual picture of HIV and AIDS cases in the province, the scenario would be a bleaker one. For the past 3 years, of the annual average number of clients availing the tests (1,900), an average of 31% are found to be positive from STI. The infection range levels can go from 27% to 38%.

It is advantageous then for Aklanons that they have 9 government and 4 private hospitals. However, only 1 public hospital is level II while the rest are level I. Nevertheless, among the privately owned ones are 2 level II and 1 level III hospitals.

COLLABORATION, BY THE DOZEN

APAC Formation. Aklan’s Provincial HIV and AIDS Council (APAC) has 20 member institutions which have been working on HIV and AIDS for the past 12 years. The formalization of these organizations’ membership to the council came only in 2006. Their own HIV advocacy and prevention efforts have started as early as 2001 though, and oftentimes in partnership with the provincial government.

Sometime in 2001, the Provincial Health Office (PHO) and the Butterfly Brigade (BB), a peer educators’ organization, began toiling on IEC and advocacy. It took five more years before Governor Carlito Marquez penned Executive Order 16 that created the APAC and defined its membership. The formal pronouncement may partly be attributed to the presence of UNFPA in the province then, as it was a partner in a Reproductive Health program.

Expanding Membership. So by 2006, national government agencies like DepEd, DOH, PNP, TESDA, DOLE, DILG, DOJ, PIA and even the President of

the LMP Aklan became council members. Others institutions not yet mentioned but are represented in the technical working groups are the Dr. Rafael S. Tumbokon Memorial Hospital (DRSTMH), League of Midwives in the Philippines (President), and representatives of health offices of two municipalities (Makato; Malay). Of course, relevant offices in the provincial government were likewise included in the membership like the SWDO, PPDO, Tourism Office, and Sangguniang Panlungsod (Health Committee).

In 2009, a non-stock, non profit, non-sectarian and humanitarian organization working on children’s rights was added as a new member (Abante Aklan, Inc.). A year after, local media (Aklan United Media Association) and an Iloilo-based youth organization (Kabataang Gabay sa Positibong Pamumuhay) were the new additions. By 2011, two more joined APAC (Aklan Chapter of the Philippine National Red Cross; Youth Aklan). The Aklan State University and Aklan Medical Society are also active council partners.

Motivations for Membership. Many of the APAC members come from agencies mandated by law. But many from the civil society organizations (CSO) volunteered. Unlike in other areas where membership in the local AIDS council is considered a ceremonial task, APAC membership has its incentives. CSO members (e.g. Abante Aklan, Butterfly Brigade, Youth Aklan) joined APAC for four reasons. One, membership is a way to show their concern for the plight of PLHIVs. Two, the council offers avenues to forge partnership and to network with other organizations based in Aklan. Three, as a result of partnerships, these organizations have widened their reach not only in the populace but with other municipal governments. Four, the council is a way for the CSO community targets to understand that they can be active partners and not just passive beneficiaries of STI/HIV/AIDS/TH programs.

Expectations from Members. The multi-sectoral members of APAC have committed themselves to contribute to IEC and advocacy, capability building, outreach and organizing, and mentoring and referral services.

Concretely, this means that they would initiate awareness-raising activities within their organizations/communities and partner in the APAC program implementation. They are also expected to look out for potential peer educators in their own organizations and actively engage in information dissemination and referral. If workable, they are expected to share some of their resources say for the production and reproduction of IEC materials should these be distributed to their own organization members. Finally, they are expected to participate in the annual World AIDS Day (WAD) celebration.

The Collaboration. From 2001 up to 2006, APAC has focused its efforts on awareness raising, advocacy and the development of info-materials for dissemination. It has also been the period of council membership expansion, formalization and competency building (especially on collaborative project management, documentation, capacity building). From then on, APAC has worked towards mainstreaming of services and integration of efforts. It has also lobbied for important policies like the 100% condom use policy.

In terms of project management, PHO convenes APAC quarterly. Council members undertake program planning, project reporting and work consolidation during these meetings. Once the plans are set, council members understand that task assignment follows. Members therefore make commitments as to what their institutions can contribute. Partnership in program implementation is explored. The meetings do not only serve as a venue for sharing of responsibilities but as an opportunity for the council members to bond.

Shared Leadership for Concerted Action. The quarterly meeting is an important practice. Without it, APAC members would not be able to tie their individual initiatives and convert them into a concerted program. Without it, redundancy and inefficiency would be unavoidable. The WAD celebration can illustrate this. During the WAD, each organization has its own plan for the celebration. These plans are presented at the APAC and

are woven together as one integrated plan. At the end of the celebration preparatory meeting, the weeklong schedule that ties all the organizations’ activities together is finalized.

In APAC, consultation is practiced. Ideas are solicited. Decisions are based on majority rule. Work assignments are not imposed. Rather, APAC members are free to accept or decline task assignments or activity support requirements.

SNAPSHOT OF 3 CSO MEMBERS

Among the APAC members, three stands out. Abante Aklan, Inc; Aklanon Butterfly Brigade; Youth Aklan.

Abante Aklan, Inc. (AAI) is a child-focused non-sectarian organization that was organized in 1999 and registered with SEC in 2000. As of 2012, it has 6,400 members from 62 covered communities in 6 municipalities in Aklan (Altavas, Batan, Madalag, Malinao, Navas, Tangalan). In 2002, it signed a stewardship agreement with World Vision to become its local partner in the province. In 2009, it was accepted as a member of APAC when it signified its interest to become a council member through a letter addressed to the Governor. AAI works on stigma reduction and awareness- raising on HIV and AIDS on its served communities.

Aklanon Butterfly Brigade, now known as the Peer Educators Council (PEC), was tapped in 2001 by PHO to be its partner for STI/HIV/AIDS prevention for the gay community. It strongly advocates for Reproductive Health, gender awareness and STI/HIV/AIDS prevention and control. The Butterfly Brigade originated from another organization, SUBEAK, which means to shine through. SUBEAK with its 75 members was formed to advance gay men’s rights in Aklan. The members of the Butterfly Brigade can initially be treated as the RH/health arm of SUBEAK. The two eventually formed two organizations, with SUBEAK currently working on expanding its membership to accommodate lesbians and the Butterfly Brigade

metamorphosing as the PEC of the APAC. The peer educators compared themselves to butterflies because they feel that they had overcome the cocoon/forming stage and are already unfurling their wings to attract people to the message they spread about STI/HIV/AIDS.

Youth Aklan is primarily composed of 13 organizations from secondary and tertiary schools. They represent the 10-24 year old population and are expected to mobilize the young people of Aklan. Through their advocacy, peer counseling, blood donation drives and other outreach activities, the organization intends to reach young Aklanons and inform them about the HIV issue. They were tapped by the PHO because the city government felt the need to involve the youth sector given the general trend of young HIV infections across the country. Specifically, Youth Aklan is expected to mobilize youth volunteers during yearly school–based orientations and HIV- AIDS awareness activities including WAD.

HIGLIGHTS OF SELECT PRACTICES

Information Generation and Campaigns. APAC members see the importance of getting the right information and delivering correct messages across. This is why kapihan for the Media (on HIV and AIDS) is a regular activity, IEC and advocacy engagements with the respective community targets of Aklan Youth and Butterfly Brigade is undertaken annually, and the conduct of relevant studies are encouraged (see boxed discussion at next page).

APAC regularly sends available PHO staff to the council member organizations to present the HIV and AIDS situationer in Aklan and to raise employee awareness. Orientation activities in secondary and tertiary schools are also regularly offered, with Youth Aklan, Peer Educators Council and PHO serving as resource persons. These kinds of information drive are undertaken year-round. PEC and Youth Aklan likewise maintains facebook accounts, specifically set-up to further disseminate information and as a venue for interaction.

WAD, a December main event. WAD is APAC’s peak activity. Given the numerous activities of the members for the WAD, the one-day celebration was transformed into a weeklong event. This results then in heightened awareness in the province and is already an Aklan State University encourages its nursing students to anticipated activity every undertake HIV/AIDS-related research for their undergraduate year. thesis.

One study looked into the risky sexual behaviors among In 2012, WAD activities selected college students (16-22 years old). The study found include school-based that the factors that influence students’ engagement in risky orientation tours, a youth sexual behaviors are peers, lover, curiosity, intoxication with drugs and alcohol, personal problems and media. What the camp, quiz bee and students consider as risky behaviors are non use of condoms, poster slogan contest, one-night stands and multiple sex partners. MDG best practices fair and info-tainment among Another study revolved around the reproductive tract infection commonly experienced by male teachers in the province. The other things. This 2013, study examined the socio-demographic characteristics of 23 the highlight is the WAD teachers and the factors influencing their perception on STI. beauty pageant aside Some of the interesting findings are (1) half of respondents are from the red ribbon within 30-39 year old range; (2) half are married; (3) 60% earn Php14,000-20,000 per month; and (4)almost all Catholics. As to campus tour of 21 tertiary their perception, the teachers shared that having multiple sex and secondary schools. partners and improper genital care may lead to infections.

Clearly targeted programs. The initial reaction when the local government learned of the first infected case was to pay attention to the regulation of entertainment establishments. PHO thus monitored the health of the establishment employees/night workers in 4 towns (Kalibo, Boracay, Ibajay, Nabas). The No Pink card, No duty Policy was imposed. For massage and bar/entertainment establishments, night workers are asked to undergo weekly STI check-ups and testing. Pink cards are issued to them once found negative but if infected, treatment is required by the Social Hygiene Clinic.

A related institutional policy is on permit requirements. For new entertainment establishments, the owner or floor manager must attend an

orientation at the SHC. New employees (called CSWs or commercial sex workers) on the other hand are asked to submit pictures, NBI clearance, birth certificate, resident certificate and relevant laboratory results before they are given their pink cards.

Gram staining services is scheduled on Mondays and Tuesdays (2013), with specific establishments clearly scheduled on which days. The clinic also keeps a tally of the number of GROs (guest relations officer) in each establishment and the corresponding number of employees with positive smearing.

The other clearly targeted program is for the MSM. From a 2002 behavior study among MSM, the Butterfly Brigade and PHO proposed to DKT Philippine’s NGO/LGU Support Program the conduct of a capacity building program and the design and reproduction of customized IEC materials on HIV and AIDS. The program ran for 10 months. It was followed by a 2003 UNFPA-funded training for MSM.

These proposals to raise the level of awareness of MSM on HIV and AIDS received immediate action given the dismal picture painted by the 2002 behavioral study. Interviewing 70 respondents, the study found that less than 1 in 3 have heard of HIV and AIDS, 7 out of 10 have misconceptions on condom use and safe sex, and more than 7 out of 10 only have limited access to RH information and services.

The creation of the Provincial Butterfly Brigade organized the first Ms. World AIDS Day Peer Educators’ Council (better (Ms. WAD) Pageant this 2013. The 15 candidates were known as Butterfly Brigade) in asked to participate in HIV and AIDS advocacy pictorials 2001 continues to be one of the in public areas like terminals, gasoline station, market, shops and shopping center, talipapa and park. The most promising initiatives the candidates also visited schools as part of the school provincial government has caravan. During the pageant night, the audience were undertaken to address the HIV asked to pay P15 as entrance fee and were given red vulnerabilities among the gay ribbons. Pageant proceeds will be used to fund BB’s HIV and AIDS related programs for 2014. community. Through the council,

APAC is able to maintain a pool of peer educators. Through PPEC or PEC, the gay community has been able to harness their energies and creativity for a good cause, e.g. through peer education mobile theater; interactive multi-media presentations , production numbers, WAD beauty pageant. All the initiatives of the PPEC on IEC fall under what they coined as Info- Tainment.

PopShop Franchise. In 2005, the province through its health officer entered an agreement with one inter-local health zone (I-B) in Makato Municipality to acquire a DKT Popshop franchise. A PopShop is a small, easily identifiable vending machine that releases RH products (condoms, pills, depot) of specific brands. It was acquired through UNFPA support and is set up at the Social Hygiene Clinic.

Seven municipalities eventually accommodated a PopShop franchise, with an initial capital requirement of P10,000. Though it made population control commodities accessible and available, it was thought to support commodity/brand reliance and was later discontinued.

Two-way Referral System. Referral slips are available at the barangay health centers and municipal health offices. The slip is to be filled at the origin health office and submitted by the client to the provincial hospital in availing services and medicines. The hospital returns a portion of the slip to the client, which he/she should return to the origin health office. Based on the 2012 AOP though, PHO is still targeting at least 50% facility implementation of the system and the manual is already made available to the health offices.

Butterfly Brigade has its own contact tracing, two-way follow through referral system through a partner notification card.

Increasing Accessibility. APAC provides technical assistance to municipal health offices to facilitate the creation of municipal AIDS Council. Complementing this is the conduct of orientation for local chief executives

so they can be recruited as advocates and partners of the cause. In this way, the provincial government is bringing the program down at the municipal level and is a way of increasing access to services of PLHIVs who may be living in the outskirts of the capital town.

Another way of increasing access is the installation of a satellite treatment hub at DRSTMH manned by HIV and AIDS Core Team at the hospital. A satellite clinic is also available in Boracay island.

On a different access point, the PHO published in 2011 a collection of best practices guidebook. It compiled the good health practices of the local governments in Aklan to serve as reference material for other local governments intending to replicate these practices or for those interested to seek technical assistance.

RETURNS FOR AKLAN

If the collaborative engagement were paralleled to a business venture, how would the business fare in terms of returns? Here are some of the gains of the province of Aklan for all its efforts since 2001.

One, APAC’s organizational growth. The Council reached a wider audience due to its more diverse and wider membership that keeps on getting bigger across the years.

Two, regular reporting. The multi-sectoral and strategic partnerships formed as an offshoot of APAC membership contributes to referrals and regular reporting to SHC of discovered cases.

Three, continuing commitment. Attendance to quarterly meetings of APAC members are still at a high 80% average. Plus, though each organization takes the lead in their own HIV and AIDS programs, they find it necessary to collaborate with the PHO and integrate their plans with the rest of the plans of the other APAC members.

Four, presence of peer educators in all municipalities. As of 2011, there are 165 gay peer educators distributed in the 17 municipalities. The pool is maintained even with the turnover of previously trained educators since about 30-35 new ones are recruited each year.

Five, only 4 remaining municipalities are without local AIDS councils - in Libacao, Balete, Banga, New Washington. Twelve finished setting up their councils, with the technical assistance of the province.

Six, higher service demand. There’s a ripple effect on the demand for orientation from schools, barangay legislators, law enforces and even some religious organizations. This is reflected in the annual school tours during the WAD celebration. The same is the trend for services from testing centers. Perhaps because more people are reached by the advocacy activities and info-tainment, the number of visits in the satellite clinics is increasing.

Seven, small budget but big activities. The annual budget of APAC from the provincial government is more or less around P365,000. Compared with the scale of APAC’s programs, this amount would not be able to finance the concerted action if not for the commitment of council members.

Lastly, full service package. Prevention to embalming services are made available.

These returns and the stories behind them are what the local governments of Nueva Vizcaya, Ifugao and CARAGA are interested in when they visited the province as a lakbay-aral site on HIV and AIDS programs.

CHALLENGES AND LESSONS

Challenges. Outlined here are some of the remaining concerns to be resolved.

Stigma. Even among hospital staff, this is a concern. There seem to be a lack of understanding on the issue even among medical practitioners. They need to be oriented and re-oriented on the guidelines and standard precautions. For potential clients, SHC felt that there is a stigma in taking the test. People are discouraged from getting tested since people automatically assume that one is HIV positive just because one wants to get tested. Others resist getting tested due to the fear of getting exposed as a freelance sex worker. Stigma reduction efforts should also start at the SHC level. PHO staff should stop using CSWs, GROs and FSWs as client labels and should start using more sensitive terms like night or entertainment workers instead.

Resource constraint. Budget for medicines for opportunistic infections is hard to come by. Fortunately, DOH usually augments APAC resources through grants. Some APAC members are likewise willing to provide resources for certain activities. Also, the province lacks equipment to undertake complete HIV tests and therefore have to send a sample to the nearest testing center for confirmation of infection status.

Value of own space. Butterfly Brigade still does not have a physical base. PLHIVs also do not have a half-way house in Aklan. A half-way house is for those who are rejected at home or by their community once they learned that they are infected.

Institutional memory. APAC members are changed time and again. New representatives are unfamiliar with previous commitments have no institutional memory of APAC’s initiatives. Each new representative has to therefore be oriented by the Secretariat.

Reality of sex trade. Though prostitution is illegal, it is a widely accepted practice in touristic areas. The Social Hygiene Clinic can only impose so much on the enforcement of the pink card requirement and condom policy. Still, it is up to the entertainment worker whether to risk getting infected.

Catholic stance. The condom policy runs counter with the position of the church. This institution would have been a strong partner if only APAC gets to enlist it as an ally.

Municipal inaction. There is a need to push some municipalities to initiate their local response on HIV and AIDS.

Lessons from the 12-year APAC Experience. On collaboration. APAC ensures that Council members are given equal importance. Regular and open communication is maintained. The Secretariat always makes the Council members feel welcome and their comments and suggestions on program activities are consistently sought. Also, integration of initiatives is the goal and attention is not focused on who takes the credit. APAC showed that LACs should create a conducive environment for the different sectors to work together. Mutual respect and recognition should always be exercised.

Membership expansion. Local governments should not limit themselves to what is provided by law. They should happily accommodate other members of the society to take part in the council activities. Such is the case in APAC, which entertained the youth, gay, children, academe and even media. It is the local government’s role to reach out and generate more champions and gatekeepers.

Appreciate diversity. Real partnership means making room for others’ opinions. This can only be forged when partners feel that their voices are reflected in key decisions and that they are involved in the council programs from conceptualization to execution and monitoring.

Go down to the community level. Make testing available not only in the capital but in other hotspots as well. Prevention education should be brought to schools. Community leaders should be tapped as well.

Inspire volunteers. A local HIV and AIDS response would falter without the volunteers; peer educators specifically. It is important that volunteers are given positive experiences during program activities as these memories would convince them to participate again and again.

Intensive year–round education campaign and well-publicized WAD celebration. In the last three years, supposedly more clients get tested during December. This can be an indication that the IECs are taking effect making people more aware and prompting them to take positive action during the WAD month.

Partner not beneficiary-driven. The Aklan experience has shown that program beneficiaries can be engaged as active partners.

Aklanons multi-sectoral approach to HIV and AIDS has consistently shown that since this is everybody’s business, it should elicit everyone’s support as well.

Military men tend to have a negative reputation when it comes to sexual behaviour. They are often disparaged as having sexual partners in every place to which they are assigned. However, it is true that localities that surround military bases and camps often have booming entertainment and recreational areas where off-duty military personnel can visit. This situation lends itself to risky behaviour that may end up in sexually transmitted infections including HIV/AIDS. In addition, the fast turn-over of military personnel due to cycles of re-assignments may result in spreading an infection to the next place of assignment.

THE STAGING GROUND

North Cotabato is a landlocked province in the center of Mindanao island. It is the northernmost province of the SOCCSKSARGEN region. To its north are the provinces of Bukidnon and Lanao del Sur, to the west by Maguindanao, to the east by Davao City and Davao del Sur, and to the south by Sultan Kudarat. Its 17 municipalities and one city occupy a 6,565.9 square kilometre land area.

Seventy-one percent of the population is composed of Christian immigrants from Luzon and the Visayas. About 16% are Muslim Maguindanao and the rest are indigenous peoples. Certain parts of the province are affected by the conflict in Mindanao. The province is the staging ground and sometimes the site of military operations. There are four brigades deployed in the province.

At the start of the MIU project, there were no recorded cases of HIV infections in North Cotabato. However, there were two suspected cases though was never confirmed. Nevertheless, the very low condom use in the province—only 2%--was cause enough to proactively introduce preventive practices to avoid the spread of infections. In addition, among the 40,000

military personnel in North Cotabato only 10 percent were practicing family planning.

MEN IN UNIFORM PROGRAM

The Integrated Provincial Health Office (IPHO) decided to have a two- pronged approach in addressing potential STI and HIV/AIDS problems. In 2005, the Men In Uniform (M.I.U.) Project was instituted by the IPHO which intended to reach out to military personnel assigned in North Cotabato. MIU aimed to capacitate military personnel and influence them to have responsible sexual practices. This intervention aims to increase male participation in family planning and increase the use of contraceptive methods. Modules on violence against women (VAW) and gender sensitivity were also included. The military personnel were later on expected to reach out to conflict-affected communities that may not be easily reached by local health personnel and train them on family planning methods. Rural health units were also involved as centers for testing and counselling.

The IPHO prepared IEC materials and a training program on the 10 elements of reproductive health including STI and HIV/AIDS, violence against women, and male participation in reproductive health.

MIU IMPLEMENTATION

The MIU Project was began in 2005 with support from the United Nations Population Fund (UNFPA). As the first phase of the project, a technical working group was formed at the IPHO to coordinate the preparatory activities for the project. Afterwards, the focal persons from the municipalities were identified. The TWG members and LGU focal persons were trained on the modules of the MIU Project. The composite team then selected the target battalions and lobbied with the commanding officers to engage their personnel.

The second phase involved the roll-out of the training program in the selected battalions. The pilot training program was implemented at the 39th

Infantry Battalion in Poblacion, Municipality of Makilala. The training was a five-day seminar-workshop on the modules on reproductive health and family planning. The MIU Project would proceed to three other units: the 40th Infantry Battalion in Aleosan, 7th Infantry Battalion in Ladtingan, Pikit, 57th Infantry Battalion in Makilala, and the 68th Infantry Battalion in Tawan- Tawan, Mlang.

Two hundred peer facilitators were trained and were expected to be the RH champions in their platoons and military camps and 1,500 soldiers underwent the orientation seminars. After the training, the soldiers were asked to select the MIU focal persons for each battalion. A symposium for all four battalions and some units of the Philippine Marines was held at Fort Pikit in the Municipality of Pikit.

The IPHO TWG met with focal persons from the battalions and the focal persons from the RHUs for planning and feedbacking on RH responses in the military units and the communities.

THE HEALTH BATTLE

Almost 2,000 military personnel were trained on reproductive health and preventive practices to avoid STI and HIV/AIDS. Condom use was raised from 5,000 to 8,000. There were even 272 vasectomy procedures performed—a stark increase from zero in 2002. The soldiers formed Task Force Magdalena which was tasked to lower the incidence of STI in camps. The LGU of Alamada also undertook training for its police officers, barangay officials, barangay tanods, tricycle drivers and high school students. The National Defense College took notice of the MIU Project and also plans to integrate RH and family planning into existing curriculum and training programs. The MIU experience was also shared in the First Asian Conference for Behavior Change for Male Participation in Reproductive Health in Yangon, Myanmar and at the 10th International Congress for Reproductive Health and Population in Manila.

UNIFORMED LESSONS?

Initially, the soldiers were lukewarm to the concept of MIU—considered a “soft” project as compared to the business of anti-insurgency or engineering. It was necessary to gain the support of the commanding officer who can cascade the buy-in through trusted personnel who can then become focal persons for the project. Regular dialogues and lobbying with the officers was a key step to gain project support. The aspects of the safety of their families and reaching out to conflict-affected communities also became an additional motivation for the soldiers’ buy-in.

Condom use needs a more intensive encouragement from the brass as condom use remains quite low.

Motivation, religious beliefs and reinforcement from religious leaders continue to affect the implementation of RH and family planning related interventions. Funding became shaky when the UNFPA exited from the project. The former head of the IPHO had to spend some personal money in order to provide food during the trainings. Sustainability is heightened when the municipal governments claim ownership of the project and implement their own initiatives to replicate the MIU model.

FIGHTING AN INVISIBLE WAR

Military personnel are exposed to many dangers in the battlefield. Dodging bullets and artillery means a life or death situation. But the Philippines is opening another front in a war which has no visible frontlines, only manifestations of the infection here and there. But the infections of HIV/AIDS are growing and even the toughest military personnel are not immune from infection if they do not practice safe sex. The MIU is an exemplary strategy that is an initiative of the local government. Taking care of military personnel is also local business. It means that possible infections are avoided in the military camps, host communities, and in future host communities when the military units have to move on to a new assignment.