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V. FINDINGS ON ACCESS TO CONDOMS AND HIV/AIDS INFORMATION IN THE PHILIPPINES

Human Rights Watch found that the ability to deliver or advocate for comprehensive HIV prevention services in the Philippines was crippled by official resistance to condom promotion. This resistance took many forms, including ordinances prohibiting condoms from public health clinics, police interference with condom promotion, weak and unimplemented policies regarding the availability of condoms in sex establishments, and the government’s refusal to supply condoms to the public sector with national funds. A failure to integrate reproductive health services into HIV prevention, particularly through the enactment of a national reproductive health policy, further frustrated access to condoms and HIV/AIDS information.

Human Rights Watch also found that anti-condom advocates continued to peddle misinformation about condoms and HIV prevention, though perhaps less publicly than in the early 1990s. The guarantee of comprehensive AIDS information in the Philippine AIDS Act proved no match for this misinformation. Interviews with populations at high risk of HIV—including sex workers, men who have sex with men, adolescents, and migrant workers and their spouses—revealed low levels of HIV/AIDS awareness, inconsistent to no condom use, and inadequate treatment and information in government health clinics.

Official anti-condom policies

Anti-condom ordinances

In some cities in the Philippines, local authorities have gone as far as to prohibit the distribution of condoms in public health facilities, at times attempting to take disciplinary action against organizations that promote condoms with private funds. The example most frequently cited by service providers is Manila City, where Mayor Jose “Lito” Atienza has issued an executive order banning all artificial birth control, including condoms, from the city’s health clinics. While Human Rights Watch did not find direct evidence of disciplinary action against service providers, many said that the ordinance was used as a basis to discipline nongovernmental organizations that promoted condoms as part of a larger family planning service. According to Dr. Jose Narciso Melchor C. Sescon, a gynecologist and director of the Remedios AIDS Foundation, Inc.:

If at any point you advocate for family planning in Manila, the next day you will have your services shut down and padlocked. I know of two NGOs who have been shut down. In one case, the wife of the mayor performed an inspection and found contraceptive commodities on the premises. The next day, their door was padlocked.⁹¹

Sescon told Human Rights Watch that in order to provide integrated HIV/AIDS and family planning services, Remedios would have to “go underground.” If a client living with HIV/AIDS needed family planning services—for example, a married woman who wanted to avoid getting pregnant or infecting her husband—she would have to be referred elsewhere. “If you deliver, if you even speak about family planning services, they’ll have a red light on your agency,” he said.

The Women’s Health Care Foundation (WHCF) is a Quezon City-based NGO that provides a range of reproductive health services and HIV prevention through a network of clinics in Metro Manila. Their clinic in Manila City reaches poor women living in squatter communities, some of whom survive by exchanging sex for money with boat workers in Manila Bay. Gladys Malayang, executive director of WHCF, told Human Rights Watch that WHCF volunteers who distributed condoms and pills in squatter communities feared that they would lose their land if they were caught by city authorities.

They actually feel they are being subversives because they are carrying condoms. . . . They feel they have to hide it, to be secretive about it. It’s like they’re dealing drugs or doing something illegal. They think the city will take their land if they find out. So access to condoms and reproductive health services is very limited.⁹²

Malayang added that government health workers, who are mandated to provide only natural family planning services, sometimes referred women seeking condoms to WHCF, because they feared losing their jobs otherwise. Women squatters would then arrive at WHCF with a cough or cold and secretly ask for condoms or birth control pills.

The mindset is that if they access condoms, they will lose their land. And the fact that it’s on their minds means it must come from somewhere. They come to us with coughs and colds and say, “By the way, can we also have some condoms?” . . . I don’t know what kind of threats have been made to make these people feel like they are violating a law by trying to access condoms.

Human Rights Watch interviewed two volunteer community outreach workers, themselves squatters, who had been trained by WHCF to distribute condoms to women in a squatter community near Manila Bay with an estimated population of 80,000. Lilibeth Buenconsejo, thirty-six, said that she distributed condoms and information to women who “climb onto the boats” to sell sex. But she kept a low profile because she knew the mayor disapproved of contraception.

It’s difficult because there are some areas where we can’t go. We don’t want stories of what we’re doing to spread, so we don’t go to areas where what we’re doing will spread. The mayor has banned family planning. We don’t want the barangay⁹³ health volunteers to know what we’ve been doing. . . . Stories get passed on, and they might tell the story of what we’re doing at city hall meetings.⁹⁴

Marisa Dela Pena, thirty-two, told Human Rights Watch that she began volunteering as a community health worker six years ago “so I could educate my neighbors, especially those who know nothing about family planning.” ⁹⁵ She also distributed condoms to women who survived by selling sex, some of them as young as fifteen. Like Buenconsejo, Dela Pena had developed strategies for avoiding disciplinary action.

We’re not standing on street corners passing out condoms, so the mayor can’t sue us or put us in jail. But if the mayor found out, he’d probably have me called into his office and ask me to explain why I do this. I would have only one answer, which is I don’t force it on the women, they come to me.

In August 2002, Dela Pena was one of several volunteers reported to the mayor for attending a training session on family planning.

The nurse in charge called us in and was demanding to know why we were having a seminar on artificial methods. I explained that we just wanted to know more. Then some of the mayor’s aides came in. They took a group of us and made us watch a video of fetuses being aborted. They kept saying that artificial family planning was the same as abortion. They said condoms are not effective and easily break.

The day after this incident, Dela Pena said, she was approached by the government nurse and urged to leave WHCF and work for the city health clinic. She said she refused, because the city clinic taught only natural family planning methods and demonized condoms. “At the government clinic, they don’t learn anything about condoms,” she said. “They just say again and again that condoms break easily and they aren’t safe.” To encourage her to leave WHCF, the city offered Dela Pena a substantial salary and a larger spending allowance than WHCF. She did not budge.

They were saying if I came to their clinic, I’d have a salary of 35,000 pesos [U.S.$622] plus an allowance from the mayor of up to 5,000 pesos [U.S.$89] per month. We only get an allowance of 1,000 pesos [U.S.$18] per month from WHCF. For me, the money is not the important thing. What’s important is being able to help my neighbors.

Gladys Malayang told Human Rights Watch that in late 2002, she was called into city hall and asked to cease distributing condoms and other forms of artificial birth control. In her defense, she questioned how the city could justify allowing drug stores to sell condoms to those who could afford them, while prohibiting clinics like WHCF from distributing condoms for free. “I asked them, why are you discriminating against your poor women?,” Malayang said.⁹⁶

Manila City was not the only jurisdiction in the Philippines that had prohibited condoms from public institutions. A similar policy existed for a time in Puerto Princesa on the island of Palawan. In Laguna, an anti-condom ordinance led to higher rates of unwanted pregnancy, unmet family planning needs, illegal abortions, and increased STI and HIV risk, according to research conducted by the School of Environmental Studies and Management in Manila.⁹⁷ Davao City did not have an explicit anti-condom ordinance, but efforts to require condom availability in sex establishments failed there because of religious opposition.⁹⁸

Confiscation of condoms by police

Sex workers and their clients face a particularly high risk of HIV infection in the Philippines, not least because the illegality of prostitution drives them and their clients underground and away from health services. Sex workers in the Philippines are generally divided into those that are registered to work in licensed entertainment establishments, and those that work freelance in either illegal brothels or the street. While all sex work is illegal, registered sex workers are required by occupational health and safety laws to undergo testing in government-run “social hygiene clinics” for STDs other than HIV.⁹⁹ The Philippine government also recommends that an ample supply of condoms be made available in sex establishments throughout the country.

Outreach workers interviewed by Human Rights Watch said that sex workers often refused their offers of free condoms, because they feared police would use them as evidence and arrest them. “It always happens,” said Noel Mandanas, a project coordinator for the NGO Kabalikat ng Pamilyang Pilipino (Kabalikat) who distributes condoms and provides HIV/AIDS and STD counseling in Pasay City. “The last time it happened, we asked one of the freelance sex workers why she was refusing condoms. She said the police might use condoms as evidence against her.”¹⁰⁰ Mandanas added that fear of arrest was one of four main reasons Kabalikat did not meet its condom distribution targets in 2003—the others being male customers’ dislike of condoms, having to charge for condoms because of supply shortages, and clients obtaining condoms from other sources.

Freelance, street-based sex workers interviewed by Human Rights Watch said that police impeded their access to HIV prevention services by confiscating their condoms, using possession of condoms as evidence of prostitution, or arresting them for “vagrancy” without any evidence of prostitution.¹⁰¹ Maria S., twenty-two, a street-based sex worker in Pasay City, said that police arrest her if they catch her carrying condoms.

If the police catch us, if they see the condoms, they’ll arrest us. They touch us all over the body and they find them. They ask, “What are you doing with condoms?” They get mad when they see us with condoms. They threaten us, like they say, “You want me to put this [the condom] in your mouth?”¹⁰²

Maria S. said that the last time police caught her with condoms, in 2003, they arrested her for vagrancy and put her in jail for a week.

I was just standing here when it happened. They handcuffed me and dragged me to the station. I cried. They accused me of vagrancy. They said, “If you don’t give us money, you’re going to jail.” So I was arrested. I had no money. I felt lonely in jail. It was hard, I just cried and cried.

Human Rights Watch heard accounts like this from numerous sex workers in Pasay City. Juliet C., twenty-three, said that police arrested her for vagrancy in January 2003 and used condoms as evidence that she had been engaging in prostitution. She spent six hours in jail before being released.

The police came up to me and said, “It’s already late,” and they arrested me. I felt degraded. They called me names. They said, “You may be beautiful, but I don’t like your vagina, because it stinks.” I spent six hours in jail. I had ten condoms with me. They used it as evidence. They said, “This is the evidence you are a prostitute.” I told them, “Just because I have condoms, that doesn’t mean I am a prostitute.” The police don’t believe that.¹⁰³

Using condom possession as evidence of prostitution is an unjust and unreliable method of distinguishing sex workers from people who are not breaking the law. It is also a surefire way to deter those who do work in prostitution from carrying condoms in public and protecting themselves, their families and their communities from HIV. “I like to have plenty of condoms in my bag,” explained Jessica R., nineteen, a sex worker in Pasay City. “But if I see the police, I throw my bag away.”¹⁰⁴

Arbitrary restrictions on condom promotion

Human Rights Watch documented a number of restrictions on condom promotion in the Philippines that stemmed not from government ordinances or police conduct, but from arbitrary actions by elected officials, government agencies and church leaders. One agency cited by service providers was the television advertising board (Adboard), which reportedly used obscenity laws to impose restrictions on television public service announcements (TVPSAs) promoting condoms. Dr. Carmina Aquino, director of the USAID-funded AIDS Surveillance and Education Project (ASEP), noted that the Adboard operated under the assumption that condoms promoted promiscuity.

Our project included funding for condom TVPSAs, but we had problems dealing with the Adboard. We wanted to air a TVPSA where a real condom comes up on the TV. It was very difficult to have this approved by the Adboard—the image of a condom on TV. . . . They didn’t want a real condom. It promoted promiscuity.¹⁰⁵

Terry L. Scott, Philippines country director of DKT International, a social marketing organization, told Human Rights Watch that “the mere fact that we can run condom ads in the Philippines is a huge, huge plus.”¹⁰⁶ He described the challenge DKT faces as “giving a message that is edgy enough without stepping over the boundary of what is acceptable.” As an example, Scott contrasted a proposed advertisement for a brand of condoms known as “Frenzy” with the version ultimately approved by the Adboard.

The ad campaign was initially designed to show a guy and woman in two separate situations where the guy had a chance for a sexual encounter. In the first, when the woman found out the guy didn’t have a condom, she stopped him. Then we go to group of women where the woman had a chance for a sexual encounter, and because neither partner had a condom, she stopped it also. . . .

I think we went through probably four or five revisions and finally went with one that was acceptable. We ended up having people go into a music store where the DJ puts on a disc called “Frenzy,” and then we have a song, the Frenzy song, and the people who have Frenzy condoms start dancing.

Scott emphasized that while the approved version was “very different from what we intended it to be,” it still met DKT’s main objective of targeting youth and promoting the brand.

At another point, Scott said that “sometimes, the external difficulties can drive you insane.” Scott recalled a 2002 incident in which the board of directors of a chain of 7-11 convenience stories, reportedly chaired by a conservative Catholic, pulled all condom stocks off its shelves after a student’s parents accused the store of distributing condoms to a minor. Also in 2002, DKT’s director of marketing, Benny Llapitan, reported that some supermarket owners had been keeping condoms inside glass shelves for fear of complaints from priests, and that some stores had already been chastised for selling condoms. Llapitan blamed the government in part for not addressing these restrictions. “We live in a country with cultural hang-ups and religious restrictions,” he said at a 2001 forum on condoms in the Philippines. “We work with a government that lacks political will. Meanwhile, the virus continues to spread.”¹⁰⁷

Anna Leah Sarabia, whose organization Women’s Media Circle produced television shows on women’s health, said that obscenity laws prevented her from talking frankly about HIV prevention on television. “We’ve had to master how to say things without saying things,” she told Human Rights Watch. “You can talk about HIV and say how bad it is. They love it when we say you can get HIV from sex, because what they want us to say is, ‘Don’t have sex.’ It’s all about abstinence.”¹⁰⁸ Sarabia described the conduct of the board of censors, the agency responsible for regulating television content, as “arbitrary.” The board levied substantial fees to review programs, she said, only to make decisions based on the political whims of the board’s director. “Like most people, we are forced to self-censor,” she said. “It costs a lot of money. It really is a form of harassment. That’s the way they control information on sex and sexuality.”

Dr. Junice Melgar, executive director of the NGO Linangan ng Kababalhan, Inc. (Likhaan), told Human Rights Watch her organization had been reprimanded by a senator for participating in the 2002 “Condoms For Life” campaign organized by the Washington-based NGO Catholics for a Free Choice (CFFC). The campaign consisted of a series of billboards and advertisements in six cities, including Manila, depicting a group of robed Catholic bishops alongside the headline, “Banning Condoms Kills.” On May 17, 2002, the chair of Likhaan’s board received a letter from Senator Vicente Sotto III, chairman of the Senate Committee on Public Information and Mass Media, stating:

I was sincerely bothered by the unnecessary and unfortunate message attributing the cause of many deaths on a group shown to be none other than the College of Cardinals, the successors of Saint Peter and the apostles in the eyes of the Catholic community. . . . In this regard, may I inform you that as chairman of the Senate Committee on Public Information and Mass Media, I am filing a resolution to look into this matter and related concerns.¹⁰⁹

Senator Sotto’s letter encouraged the advertising industry to engage in self-censorship, stating that “whenever the sentiments and good sense of a specific portion of the community is offended, the creative departments of the industry should take the cue and review its content and delivery of the message.” Manila Archbishop Jaime Cardinal Sin responded to the CFFC campaign by reiterating his opposition to condoms, telling reporters, “I maintain the Church’s stand against condoms and artificial contraception. We must always stand up for what is right even if we are pressured by groups like the CFFC.”¹¹⁰

Some experts told Human Rights Watch that the pervasive threat of church opposition had placed a chilling effect on efforts to promote condoms in public places. Dr. Michael Tan, a leading AIDS expert and professor of anthropology at the University of the Philippines, said that university administrators had refused to install condom vending machines in campus bathrooms because “there’s this fear the Catholic church will come breathing down their necks.”¹¹¹ According to Tan, the university health service provided no condoms for HIV prevention, no sex education, and nothing that could be construed as a family planning service.

Weak “100 percent condom” policies

Part of what allows local officials, police and government agencies to restrict condoms in the Philippines is the absence of a clear national policy on condom promotion. Thailand’s “100 percent Condom Campaign,” whereby entertainment establishments were required to make condoms available to sex workers and their clients, is often cited as an example of a policy that can enhance local HIV prevention efforts, particularly where the policy is supported by national leadership and a commitment to gender sensitivity.¹¹² Advocacy by USAID and other donors in the 1990s led several local government units (LGUs) in the Philippines to enact “100 percent accessibility of condoms” ordinances. However, service providers from many of these LGUs told Human Rights Watch that these ordinances were difficult to enforce without a national policy on condom promotion, and that many were unfunded from the moment they passed.

Wilfred Bidad, director of the Social Health Environment Development Foundation in General Santos City, told Human Rights Watch that “[t]he ordinance says that 5 percent of the health budget goes to HIV prevention, but this money is seldom accessed by service providers.”¹¹³ Bidad and other service providers stressed that the problem was not a lack of funds, but poor accounting procedures and a refusal on the part of local governments to release the money. “We were about to submit a proposal, but the government doesn’t consider it a priority,” said Femia T. Baldeo of the Pearl S. Buck Foundation in Quezon City.¹¹⁴ She added:

They have the money. It’s a matter of political will. They prefer other types of programs—more tangible programs that will build their good image. HIV prevention is not tangible. You can’t see the immediate effect unless there’s a big pandemic.

Not surprisingly, service providers said their programs had suffered considerably since USAID funds dried up and many local governments refused to fill the void. “Before, we employed nine staff and forty-six peer educators,” said Maria Lourdes Lim of Human Development and Empowerment Services, a former USAID sub-grantee in Zamboanga City. “That’s all gone now.”¹¹⁵ Noel Mandanas of Kabalikat added that his program began having to charge sex workers for condoms once the USAID program ended.

Service providers noted that the absence of a national policy on condom promotion made it difficult to implement 100 percent condom policies locally. Without a national training program for police, for example, training was needed every time an officer transferred jobs. “Changes in local government structure, especially among police, create a need for new gender-sensitive training every time there’s a turnover,” said Wilfred Bidad.¹¹⁶ An additional problem was that local governments felt unmoved to pass 100 percent condom ordinances in the absence of a national example. Gladys Malayang, director of the Women’s Health Care Foundation and a member of the Philippines National AIDS Council (PNAC), put it this way:

There is no national policy on condom use in the Philippines. . . . I asked PNAC why not, and they said it was too politically charged. We were hoping for something like Thailand’s 100 percent condom policy, just to send a message to local government offices about STDs. Instead, the message that’s coming through is more the Vatican message. . . . Politicians think that if you say something about condom use, you will lose the next election.¹¹⁷

Malayang noted other effects of a lack of national condom policy, such as the refusal of the Department of Health in 2003 to issue a statement about condom use on World AIDS Day. Because World AIDS Day events were to be held in Manila City, Malayang explained, the Secretary of Health agreed not to mention condoms for fear of offending Manila’s pro-life mayor, Jose “Lito” Atienza.¹¹⁸ AIDS service providers reportedly discussed boycotting the event, eventually holding a separate World AIDS Day event in nearby Quezon City.

Refusal to fund condom supplies

As of this writing, the Philippines faces what could be an unprecedented crisis in condom supplies. In 2002, the United States government announced that it would no longer be supplying the Philippines with condoms or other contraceptive commodities, choosing instead to encourage condom purchases by the Philippines Department of Health.¹¹⁹ USAID had previously donated up to 80 percent of the condoms supplied by the Philippines government. According to experts interviewed by Human Rights Watch, the subsequent refusal on the part of the Department of Health to compensate for the USAID pull-out was putting a critical strain on condom supplies in many parts of the country. Senator Rodolfo Biazon, an advocate for reproductive health rights in the Philippines, told Human Rights Watch:

I visited a rural health clinic in November 2003, and many of the barangay health workers were showing me empty containers of condoms. In some cases, health workers had taken the initiative of forming themselves into co-ops, buying from the source and selling them at 60 percent of the drug store cost. This was with their own money.¹²⁰

A representative of the United Nations Population Fund, which provides technical assistance to the Philippines government on condom procurement and distribution, told Human Rights Watch in late January 2004 that public health clinics in the Philippines had a three-month supply of condoms left. “A decision has to be made immediately,” he said. “In three months, it’s supposed to be zero. There are areas now that don’t have any supplies—many municipalities.”¹²¹

Experts stressed that this projected shortage was not simply a result of fiscal constraints, but of the Arroyo administration’s investment in programs that discouraged condom use. In October 2003, the Philippine Star reported that Arroyo had taken P70 million [U.S.$1.24 million] from a fund allocated to contraceptive programs under former President Joseph Estrada and awarded the sum to the NGO Couples for Christ (CFC) to provide natural family planning (NFP) programs.¹²² CFC is an organization that makes misleading statements about contraceptives in its official literature and promotes NFP through an explicitly religious message.¹²³ A 2003 edition of CFC’s newsletter, Ugnayan, states that “we cannot accept unnatural means, such as contraceptives. This is against not just morals but also against nature.”¹²⁴ The newsletter further criticizes family planning programs for engaging in “nefarious activities” and promoting “the gay lifestyle, including gay marriages.” As of March 2004, CFC’s “Statement of Philosophy” stated, “We believe in marriage as an indissoluble institution as taught be [sic] our Lord Jesus Christ (Mt 19:6); and that God created marriage primarily for love between man and woman, and for the procreation and proper rearing of children.”¹²⁵

Population expert Dr. Corazon Raymundo said of the government’s investment in NFP, “As a citizen of this country, I find it embarrassing.”¹²⁶ With typical use, natural methods result in unwanted pregnancy within one year in an estimated 25 percent of cases.¹²⁷ Raymundo told Human Rights Watch that NFP programs had gained only minimal acceptance among Filipinos, and that they could have an adverse impact on HIV prevention by discouraging people from using condoms. While awareness of HIV/AIDS had persuaded Filipino men to use condoms instead of natural methods, she said, the government’s financing of natural methods threatened to undo this progress.

By January 2004, HIV/AIDS advocates in the Philippines were beginning to feel the effects of the pending condom supply crisis. Noel Mandanas, who supervises sex worker outreach programs for the NGO Kabalikat, told Human Rights Watch that his organization had stopped receiving free condoms in early 2003.¹²⁸ Since then, their only option was to purchase condoms from the social marketing organization DKT International, which sold them at a subsidized price of P2.5 – P10 [U.S.$0.04 - $0.17]. Mandanas said that Kabalikat only distributed 13,000 of their projected 20,000 condoms in 2003, in part because they could not afford adequate supplies. While condoms could be provided cheaply by donors, they were beyond the means of small NGOs and even more unaffordable to their clients.

Jomar Fleras, president and CEO of the NGO Reachout Foundation International, said that condom shortages were a problem in Angeles City, home to a large sex industry dating back to the former U.S. military presence in the Philippines. “There are no condoms in the system, so everyone has to buy them,” Fleras said. “Some are not using them. A lot of freelance sex workers may use a condom for the first couple of customers and then stop.”¹²⁹ The country coordinator for UNAIDS in the Philippines, Maria Elena Borromeo, observed that it was the street-based sex workers, not the establishment-based ones, who could not afford to buy condoms. “The only source of condoms right now is DKT,” she said. “And freelance sex workers can’t afford condoms, even if they’re cheap.”¹³⁰

Dr. Jose Sescon, executive director of the Manila-based Remedios AIDS Foundation, Inc., noted that condom shortages had never been a problem under President Fidel Ramos, whose health secretary, now Senator Juan Flavier, championed the use of condoms against AIDS. “When Senator Flavier was secretary, the department of health supplied us with big boxes of condoms, volumes and volumes of them. Now they just supply us with those small boxes.”¹³¹

Human Rights Watch asked a representative of USAID, Dr. Corazon Manaloto, whether USAID was concerned that its decision to stop supplying condoms to the Philippines might adversely affect HIV prevention efforts. Manoloto responded that USAID’s strategy was to promote acceptance for socially marketed condoms sold at subsidized rates in the commercial sector, and to encourage local government units (LGUs) to purchase condoms with local funds. “The Philippines should become self-reliant rather than depending on donors forever,” she reasoned.¹³² At present, only a small fraction of LGUs in the Philippines purchase condoms, and many populations at risk of HIV infection cannot afford even subsidized condoms.

A project officer for the European Union Commission, Ma. Rita R. Bustamante, told Human Rights Watch that the Commission had “not [been] aggressive enough” in confronting the Arroyo administration on condoms. Taking a more aggressive posture would be a “big disaster,” she added, saying:

We know for a fact there has been a government decision to align with the church. There could be a backlash. Why be controversial when we can do it without being controversial? Why rock the boat by speaking boldly? . . . In the end, it will just be an exchange of words here and there, and that will be it. We are doing quite well without being too noisy about it.¹³³

Bustamante added that in this environment, the EU could accomplish more by advocating for condom promotion at the local level, and in that respect had made some progress by supporting the HIV-prevention activities of some local NGOs.

Other donors, such as UNFPA, had not implemented a strategy for addressing the Philippines’ encroaching condom shortage. A UNFPA programme officer, Dr. Moises Serdoncillo, told Human Rights Watch the agency had been providing technical assistance to the Philippines Department of Health on condom procurement; however, he added that the Department of Health had not shown any willingness to procure condoms, and that the national government “is not even promoting their use.”¹³⁴ Some LGUs were purchasing condoms with local funds, he said, but he did not know how many. Nor was the UNFPA official able to provide an estimate of the number of condoms needed for HIV prevention in the Philippines, or how that demand was going to be addressed in the short term. Asked what would happen in three months’ time, he said, “I don’t know. The stock will be gone.”

Opposition to reproductive health legislation

The development of a national reproductive health policy in the Philippines would have gone a long way towards facilitating access to condoms and HIV/AIDS information at the local level, according to experts. But efforts in 2003 to enact a comprehensive reproductive health bill, which would have included provisions on HIV/AIDS and a budgetary allocation for condom supplies, were successfully blocked by the Catholic church. In May 2003, the Catholic Bishops Conference of the Philippines (CBCP) issued a pastoral letter opposing the enactment of reproductive health legislation, to be read at every Sunday mass in the country.¹³⁵ Although survey data suggest that most Filipino Catholics support candidates who promote family planning, the letter was intended to create the impression of popular support against reproductive health.¹³⁶

The issuance of a pastoral letter formed part of the church’s larger strategy of using its institutional influence to block reproductive health legislation. In August 2002, CBCP president Archbishop Orlando Quevedo warned politicians over church radio that “we will remember you in the next elections” if they supported the bill.¹³⁷ Representative Neric Acosta, one of the co-authors of the reproductive health bill, told Human Rights Watch that in 2003, the bishop of his district organized two demonstrations against him for supporting the legislation, putting his name and face on billboards and “branding me as the devil incarnate.”

I was vilified in two really big church-sponsored events where Catholic schools sent their children. . . . They handed out so-called petitions, petitioning us to withdraw our support for the bill. And they had all of these schoolchildren, who had nary an idea of what it was, signing these petitions, denouncing us, denouncing the bills in Congress on reproductive health and population, saying that’s just the work of the devil. And then the bishop went on the media saying there were twenty-some thousand signatories, and so Congressman Acosta should heed this, as this is the voice of the people. . . . For a whole week, I almost couldn’t eat.¹³⁸

Acosta said that the first demonstration, in April 2003, was advertised as peace rally against the U.S.-led invasion of Iraq, an issue on which he saw eye to eye with the church. “And then the peace rally became a family rally and a pro-life rally,” he said, “and then before you knew it, I was the subject of their wrath and indignation.”

Acosta also learned that students of Catholic schools had been required by their teachers to attend the rallies, and that some had signed the petitions under pressure. “I talked to a number of high school students who went to these rallies,” he said. “I talked to some of their parents, and I said, ‘Did they know why they were there, did they know why they were asked to go there?’ They said, ‘No, we were on a field trip of sorts, we were required, we were going to get extra credit for religion class or something’.”

False scientific claims about condoms

Condom opponents in the Philippines have a long history of making false scientific claims about condoms in order to buttress their moral arguments. On August 14, 1994, Jaime Cardinal Sin reportedly told an estimated crowd of 1 million Filipinos that “the tiny AIDS virus . . . can pass right through the pores of the condom.”¹³⁹ A similar claim appeared in a pamphlet published by the NGO Pro-life Philippines, which reproduced a diagram of various sperm sizes prepared by researchers at Johns Hopkins University and concluded that “[t]hese manage to escape through flaws or minute fissures with sufficient regularity to cause pregnancy and render the condom quite an ineffective method of preventing pregnancy.”¹⁴⁰ As of this writing, the website of Pro-life Philippines states, under the heading “What is AIDS:”

Do condoms prevent the spread of AIDS?

NO. And there are other harmful things that condoms do:

1. Condoms tell people that promiscuity is all right.

2. Condoms offer false assurances from HIV infection.

3. Condoms trivialize sex and reduce it to a plaything.¹⁴¹

In 2002, when the NGO Catholics for a Free Choice posted a billboard in Manila opposing the Vatican’s stand on condoms, some conservative Catholics responded by citing evidence of condom ineffectiveness.¹⁴²

Volunteers for the Women’s Health Care Foundation in Manila City told Human Rights Watch they had witnessed family planning seminars in government health clinics in which nurses taught that condoms contained holes.¹⁴³ This testimony was corroborated by WHCF director, Gladys Malayang.

There is no information given in any government health center about condoms—no posters, no leaflets, no flyers. Only natural family planning. City health workers say condoms are bad for your health, banned by Manila City, and banned by the Catholic church. They say they have holes in them. That’s what they’re saying, and a lot of people are beginning to believe it.¹⁴⁴

Some members of influential Catholic organizations in the Philippines expressed more moderate views on condom effectiveness. The director of HIV prevention programs at Catholic Relief Services described the approach of her organization as follows:

We do not promote the use of condoms, although we give the information. You can’t help but give information. . . . I’m not the one doing the teaching, but our teachers give the truth—that it’s not 100 percent effective, that there are still risks.¹⁴⁵

Sr. Oneng Mendoza, a representative of Caritas Manila, told the 2001 media forum sponsored by the AIDS Society of the Philippines that “I am not condemning the condom but I think it is a good springboard to talk about sex and sexuality . . . [I]f only we could depart from talking about the condom and its supposed lack of efficiency or its connection with promiscuity.”¹⁴⁶ The director of a network of homes and drop-in centers for women and children affected by HIV/AIDS, Sister Mary Soledad (Sol) Perpinan, told Human Rights Watch, “The church may take a stand against condoms as contraception, but when used to prevent a deadly illness, the right to life is higher.”¹⁴⁷

The impact of disparaging condoms on actual HIV risk behavior is “debatable,” according to a 2003 report of the Health Action Information Network (HAIN).¹⁴⁸ In 2001, anthropologist Michael Tan argued that a significant number of Filipinos shunned the use of condoms and that their reported reasons for doing so closely reflected church orthodoxy. “The second leading negative attitude toward condoms consisted of feelings of embarrassment at having to buy a condom at a store,” Tan wrote, referring to a survey of young adults. “Certainly, those feelings come from the way religious conservatives have depicted condoms, associating them with illicit sex and claiming that condom distribution promotes promiscuity.”¹⁴⁹

Human Rights Watch asked the Philippines Secretary of Health, Dr. Manuel Dayrit, how his department responded to false scientific claims about condoms, particularly claims of condom porosity. “We take that as part of the pot of information that goes around,” he said. “So in that instance we would get a second opinion and find out from the manufacturer or whoever if that is an accurate statement. . . . We wouldn’t just accept it at face value unless the evidence was shown.”¹⁵⁰As of this writing, the website of the Philippines Department of Health states that “safe sex” is “not strongly recommended as an HIV prevention strategy, but mentions “correct and consistent use of condoms” as an option “for people who cannot abstain from sexual contact or who cannot maintain a mutually faithful relationship.”¹⁵¹

Some experts felt that the admonition to “be faithful” to one’s partner exposed people to HIV risk just as lying about condoms did, especially people who could not guarantee their spouse’s fidelity. “Women will say, ‘but God will protect me, my husband would never do that’,” said AIDS educator Anna Leah Sarabia. “The realization that their husband is not faithful is more shocking to them than testing positive for HIV.”¹⁵²

Misinformation about condoms and HIV/AIDS among vulnerable populations

Human Rights Watch interviewed numerous individuals at high risk of HIV/AIDS in the Philippines, including male and female sex workers, men who have sex with men, young adults, and migrant workers and their spouses, about their knowledge of HIV/AIDS and how to prevent infection. Given the country’s restricted HIV/AIDS policy environment, it came as no surprise to find that these populations subscribed to dangerous myths about the disease. These myths prevailed despite the fact that domestic law in the Philippines guarantees access to complete HIV/AIDS information in the country’s schools, health facilities, work places, pre-departure seminars for overseas workers, tourist destinations, and local communities.¹⁵³ Especially troubling was the fact popular opinion sometimes reflected—and exacerbated—negative stereotypes about people living with AIDS.

Sex workers

Human Rights Watch interviewed both registered and unregistered sex workers in the Philippines, the former referring to men and women who work in regulated entertainment establishments, and the latter to those who work in illegal brothels or the street. Numerous sex workers said they did not know anything about HIV/AIDS or how to prevent it. Clara S., nineteen, a registered sex worker in Angeles City, told Human Rights Watch.

I’ve heard of HIV, but I don’t know anything about it. I don’t even have a guess. I really don’t know anything. I don’t know anything about condoms, either. None of my customers has ever used one. I really don’t know their purpose. I think maybe the other girls use them—I don’t know why. I’ve seen them, but I don’t know how to use them. Once the other girls were telling jokes about them. My best friend told me a condom was something you could eat, like chewing gum. It made me laugh and wonder if it was really true.¹⁵⁴

Non-registered sex workers, who worked in illegal brothels or in the street, had similar stories to tell. Leah P., twenty-nine, said she worked illegally in a brothel but attended a government-run social hygiene clinic in Angeles City for routine health care. She said she had learned nothing about HIV/AIDS from the clinic:

I don’t know anything about HIV or AIDS. I’ve heard the word from my customers and people I work with. Some people say that if you have sex with really handsome guys, that’s how it starts. Some people say it starts with blow jobs—that’s why I don’t do blow jobs. I’m too scared.¹⁵⁵

Leah P. said that she sometimes used condoms, but that the most effective way for her to prevent HIV was to wash with water after sex.

I’ve heard that if you use a condom, you can avoid [HIV]. I use them sometimes, let’s say out of ten times, maybe once. Most of my customers don’t like them, so to keep clean after sex, we’ll wash ourselves. I don’t know how effective condoms are against sickness. We wash the sperm from the men right away, because we think it’s very effective to use water to wash. . . . What I do is, right after sex I wash myself right away. I’ve been pregnant twice. Both times it was unplanned.

Government surveys of condom use among sex workers in the Philippines show low levels of consistent condom use, as well as decreases in consistency of condom use over time in numerous cities. Only 30 percent of registered female and freelance sex workers reported consistent condom use in 2002.¹⁵⁶ In one city, consistent condom use among registered sex workers decreased from 68 percent in 1997 to 11 percent in 2002, even though the government had established HIV prevention programs and sentinel surveillance in this period.¹⁵⁷ In another, consistent condom use among freelance sex workers decreased from 58 percent in 1997 to 18 percent in 2002.¹⁵⁸

Condom use and HIV/AIDS knowledge was equally low among male sex workers, according to interviews conducted by Human Rights Watch. Joel R., twenty-two, a registered sex worker in Angeles City, said that he had sex with male and female customers “at least three times a week, sometimes more,” but did not know how to protect himself from HIV.

I was tested at the social hygiene clinic for tulo,¹⁵⁹ that’s it. . . . They didn’t tell me anything about HIV. I don’t know anything about it. I know what it means—to me, it means you don’t have much more time. I don’t know how you get it, or who has it, or where it exists. I heard about it on TV.¹⁶⁰

Asked what he knew about condoms, Joel R. said:

I would guess a condom is about 60 percent effective against AIDS. I don’t know, maybe you can also catch AIDS through kissing. To protect myself, I clean myself after every customer. I brush my teeth and wash my body.

Many sex workers interviewed by Human Rights Watch subscribed to dangerous myths about condoms, including that they were not necessary with a usual sex partner.¹⁶¹ Jane Perez, program coordinator for the Angeles City AIDS Council, observed that in her city, “the sex workers only use condoms for their one-time partners, but not for their regular partners.”¹⁶²The belief that condom use is unnecessary in long-term or single-partner relationships is especially dangerous for people whose regular partners engage in extramarital sex without consistently protecting themselves. Richard P., thirty-two, a sex worker in Quezon City who also has a girlfriend, told Human Rights Watch that he did not use condoms with all of his customers, because “sometimes . . . I know the customer, and that he can’t have multiple partners besides me. I know because he tells me.” But Richard P. did not use condoms with his girlfriend because, as he put it:

We’re like husband and wife. Our sex life is mutual, ordinary. We enjoy each other. We don’t use condoms. We know each other. I know that she has no relationship with anyone else. And I know that I’m safe.¹⁶³

Richard P. added that his girlfriend did not know he worked in the sex industry, because “she would not accept it.”

Other sex workers interviewed by Human Rights Watch harbored unfortunate prejudices about HIV/AIDS, including that people with AIDS or STDs were recognizable by their symptoms. “I don’t use condoms—I never have,” said Jericho M., twenty-four, a registered sex worker. “The customers don’t look like they have any sicknesses.” Asked what a “sick” person looked like, Jericho M. shrugged and said, “I don’t know. They looked healthy. They didn’t look like they were sick.”¹⁶⁴

Men who have sex with men

Filipino men who have sex with other men, some of whom assume feminine traits and identify as bakla or “queer men,”¹⁶⁵ face a disproportionate vulnerability to HIV/AIDS. Deep stigma, often manifested by outright violence and discrimination, can drive men who have sex with men away from mainstream health services and toward anonymous, casual, and unsafe sexual encounters. As of 2002, 83 percent of reported AIDS cases in the Philippines were attributed to sexual transmission, of which 21 percent involved male-to-male sex.¹⁶⁶

Men who have sex with men interviewed by Human Rights Watch subscribed to a number of dangerous myths about condoms and AIDS. “I don’t ask men to use condoms, because I know them,” said Syper T., eighteen, who sometimes accepted money from men to have sex.¹⁶⁷ Syper T. said he also had sex with girls, but men often approached him to buy sex in a pool hall in Pasay City. “When I have sex with girls, they’re not sick,” he said, asked whether he used condoms. “They’re not like women who sell themselves.”

Men who have sex with men also said that condoms reduced sexual pleasure. “There’s no thrill if you use it,” said Syper T. Aramina F., twenty-one, who said he exchanged sex for money with taxi drivers in Pasay City, said, “I hardly ever use them [condoms]. The customers usually don’t want condoms. They say it’s a bother, that it disturbs them.”¹⁶⁸

Unpublished research provided to Human Rights Watch by the NGO Progay Philippines focused on a number of health issues, including access to condoms, faced by eighty Filipino bakla in Manila and Baguio City. The research concluded that “[d]espite many attempts to share information for safer sex in gay communities, the bakla in many poorer communities do not seem to have heard that condoms are also for gay sex.”¹⁶⁹ This may have been because, as one bakla pointed out, condoms were perceived solely as a method of contraception. Of eighty bakla interviewed, only one reported consistent condom use for anal sex.

Even for men who had sex with men and used condoms consistently, Human Rights Watch found that harassment by police could increase HIV risk. “Trina F.”, twenty-one, told Human Rights Watch he had learned from an NGO that condoms could prevent HIV and other STDs, but “some police just take the condoms.”¹⁷⁰ On one occasion in November 2003, Trina F. was apprehended by police after a friend of his offered sex to an undercover officer. “They found a condom on one of my friends because it was hanging out of his pocket,” he said. “It seemed like they got harsher with him because they had evidence.”

Adolescents and young adults

For the approximately 16.5 million Filipinos aged fifteen to twenty four, lack of complete information about HIV prevention, including information about condoms, can be a death sentence. The 2002 Young Adult Fertility Survey (YAFS), a survey of almost 20,000 Filipino adolescents from sixteen regions, found that 23.5 percent of respondents had engaged in pre-marital sex, the majority of which was unprotected.¹⁷¹ Only 27.5 percent of sexually active males and 14.9 percent of sexually active females reported using contraceptives of any kind for their first sexual experience. For their most recent sexual experience, 26.6 percent of males and 21.8 percent of females reported using contraceptives. Adolescents said they had sex to “express love” (40 percent), “release an urge” (14 percent), and satisfy “curiosity” (20 percent). Of those who had engaged in pre-marital sex, 35 percent said they had more than one partner, and 11 percent said they had sex with a same-sex partner.

In 2002, the United Nations reported that most of the world’s young people “have no idea how HIV/AIDS is transmitted or how to protect themselves from the disease.”¹⁷² This observation is borne out starkly in the Philippines, where 73.4 percent of a sample of youth aged 15-24 said in 2002 they thought they had no chance of getting AIDS.¹⁷³ This figure is even higher than it was in 1994, when it stood at 72.8 percent. While 95.1 percent of YAFS respondents said in 2002 they had heard of AIDS, 27.8 said they thought AIDS was curable, compared to 12.5 percent in 1994. This suggests that knowledge of HIV/AIDS among Filipino youth is decreasing over time.

In Manila City, where the mayor had banned condoms from public health clinics, NGOs that specialized in school-based sex education found it difficult to deliver their services. Dr. Marilyn A. Pajel-Calilung, executive director of the NGO Kabalikat, said that sex education there is limited to basic human anatomy, without any discussion of sexual health.

You can’t even begin to discuss reproductive health in any schools in Manila City. . . . The Department of Education claims they have reproductive health included in their curriculum, but when they discuss it in schools, it’s just on the surface. They discuss human anatomy, but not its implications for behavior, economics and risk. It’s a big issue. If we teach students how to use condoms, they think we are also provoking or encouraging them to have sex.¹⁷⁴

Corazon Raymundo, the principal author of YAFS, concurred. “Technical information is not what young people need,” she said. “Youth need people to talk to when they feel something they can’t explain. These are things you can’t learn from sex education as it is here in the Philippines.”¹⁷⁵

The very provision of the Philippines AIDS law requiring HIV/AIDS education in schools contains a confusing clause mandating that such education “not be used as an excuse to propagate birth control or the sale or distribution of birth control devices.” This clause was inserted to placate religious leaders, who worried that HIV/AIDS education would eventually lead to artificial contraception and abortion. HIV/AIDS educators interviewed by Human Rights Watch found this provision impossible to comply with. According to Marilyn Calilung of the NGO Kabalikat, which provides school-based HIV/AIDS education in Metro Manila:

The Catholic church says that if you want to teach about condoms and AIDS, you can’t mention birth control. But how can you distinguish one use of condoms from another? If we are working on STIs and HIV/AIDS, how can we definitively say we are using condoms exclusively for HIV/AIDS? You can mention it, but to define it as two separate things is impossible.¹⁷⁶

Calilung added that principals or guidance counselors sometimes vetted their teaching modules in advance to ensure they did not contain information about artificial birth control such as condoms. “In one school,” she said, “we have difficulties because our contact person, who is a guidance counselor, does not believe in our project and has misconceptions about reproductive health.” She added:

I think the school officials are in a state of denial. They think the condom is not important or necessary, or that it’s a sin. I think the issue is that if you teach students how to use condoms, they think you are provoking them to engage in sexual activity.

The testimony of Prue S., sixteen, illustrates the detrimental impact of family planning lessons that discuss only natural methods on HIV prevention. A high school student in Baguio City, Prue S. told Human Rights Watch that he thought that the “calendar method”— a term commonly used in natural family planning materials to refer to the timing of sexual intercourse according to the fertile phases of a woman’s menstrual cycle—was an effective method of HIV prevention. He described the application of the calendar method to HIV prevention as follows:

There’s a certain day or time when you’re going to have contact with HIV. . . . With the calendar method, there has to be a gap—it can be a week, or two weeks, it doesn’t matter how long—since the last time you had sex, and this gap is agreed upon by both partners. I learned this from a pamphlet. You can do calendar and condoms. One of my gay friends had contact with his boyfriend and he got STDs, because he was doing it every night.¹⁷⁷

While Prue S. could not identify where he saw the “pamphlet” containing this information, his testimony illustrates the dangers of not providing complete information about both behavior change and condom use.

In educating students about HIV/AIDS, schools in the Philippines have to compete with anti-condom messages delivered in some churches. According to YAFS, 18 percent of Filipino youth think that their religion is against family planning. Nelly P., fifteen, told Human Rights Watch that she had learned in church that condoms were only a method of family planning, and an unadvisable one at that.

In church, they say abstinence is the most important thing, and that if you’re already married, why would you want to have sex with other people? They really stress morality. I think condoms have been mentioned, but more in conjunction with family planning. They’ll say, Why would you try to prevent God’s work?¹⁷⁸

Nenet L. Ortega, who does school-based HIV/AIDS education in Manila for the Remedios AIDS Foundation, Inc., added that private Catholic schools were particularly resistant to condom education. “One school said to us, ‘No, you can’t say anything about condoms’,” Ortega said. “We said, ‘OK, if that is your wish, we won’t discuss anything about condoms—just abstinence and monogamy’.”¹⁷⁹

Overseas Filipino workers

The government of the Philippines actively promotes overseas employment, yet its laws and policies do not adequately inform migrant workers of their high vulnerability to HIV/AIDS.¹⁸⁰ This vulnerability stems from a myriad of factors, including homesickness and the desire for sexual contact, unwanted sex (including sexual violence) in the workplace, economic pressure to engage in paid sex to augment income, and vulnerability to sex trafficking.¹⁸¹ The Philippines AIDS Act requires migrant workers to attend a pre-departure orientation seminar (PDOS), which includes a module on HIV/AIDS prepared by the Philippine National AIDS Council.¹⁸² Experts have observed, however, that the HIV/AIDS component of PDOS is truncated, not integrated into the overall discussion of migration realities, and, like the PDOS itself, conducted immediately before departure when the worker is preoccupied with other business.¹⁸³

Malou Marin, executive director of a nongovernmental organization specializing in migration and HIV/AIDS, told Human Rights Watch that she did not offer her organization’s services to PDOS, because she felt the process was flawed and that her time would be better spent educating departing migrants and their families at the community level. “HIV/AIDS is often neglected,” Marin said of PDOS. “They just do the basic stuff, which isn’t relevant to most overseas workers. It’s AIDS 101 without any links to migration.”¹⁸⁴

Human Rights Watch met Noel P., forty-five, at a home for people living with HIV/AIDS in Manila. Noel P. said he had become infected with HIV in 1999 as an overseas worker in Riyadh, Saudi Arabia. At the time, he said, “I didn’t know the mode of HIV transmission. I only knew AIDS was a scary disease.” His attitude toward condom use had been shaped in part by what he learned in church.

Before I got AIDS, I used to say, “I’m a Catholic, I don’t use condoms” . . . . It’s what I learned in church—they are so stuck in procreation. . . . I was on vacation in Dubai, and I took a girl into a hotel, thinking it [AIDS] wouldn’t happen to me. When I got home, I went for voluntary testing and that’s how I found out.¹⁸⁵

Noel P. added that he did not receive adequate post-test counseling when he tested positive for HIV, only prejudice from a health care worker. “I remember that the doctor wanted me to sign for the test results, but she didn’t want me to use her pen,” he said. “I thought, ‘Oh God, this is the one preaching to me about how to avoid HIV transmission?’”

The spouses of migrant workers, no less than migrants themselves, also face a high vulnerability to HIV/AIDS when they are not provided with adequate information. Despite this, the only HIV/AIDS programs for spouses of migrants in the Philippines are carried out by NGOs.¹⁸⁶ Immediate deportation of migrant workers who test positive for HIV, which is a policy in many countries where Filipinos work abroad, further marginalizes workers and their spouses from support services and counseling after the migrants return home. Without proper counseling, many spouses of migrants cling to the myth that fidelity in marriage will protect them from AIDS. “It is a religious belief here that if someone is my partner, I will protect him, and he will protect me,” said Michael Tan. “This is only reinforced by the message that condoms don’t work.”¹⁸⁷

Aimee V., forty-one, told Human Rights Watch her husband infected her with HIV after he returned from a one-year overseas contract in South Africa.

I didn’t know anything about HIV before I was infected. . . . My husband had been an OFW [overseas Filipino worker] in South Africa, and I didn’t know he was infected. . . . When my husband came home, we didn’t use condoms, because I’d already gotten my tubes tied. . . . I thought condoms didn’t have any effect on AIDS. I thought they were just for family planning.¹⁸⁸

Aimee V. said she did not find out her husband was HIV-positive until three days before he died, in 1997. By that time, she had been having unprotected sex with him for four years. She also realized that she had breastfed her youngest child until 1994, one year after her probable infection with HIV. She tested positive herself in 1999 but did not have the courage to have him tested. “I can’t handle it,” she said. “I have no money for treatment.”

Sex workers: human rights abuses fuel misinformation

The illegal status of all sex workers in the Philippines predisposes them to HIV infection by impeding their access to information and prevention services. As of December 2002, nearly one-fifth of reported AIDS cases in the Philippines had occurred among men and women working in entertainment establishments, where sex is frequently exchanged for money.¹⁸⁹ Human Rights Watch documented numerous violations of the rights of sex workers, ranging from forced HIV testing to denial of complete HIV/AIDS information, that elevated their risk of HIV infection.

HIV and STD testing and counseling

As noted above, Philippine law requires sex workers who are employees of licensed entertainment establishments—sometimes known as “registered sex workers”—to receive regular screening for STDs other than HIV in government health facilities known as social hygiene clinics. These clinics date back to the U.S. military presence in the Philippines, when American soldiers fueled a high demand for sexually available Filipina women and the U.S. military sought to protect their troops from STDs.¹⁹⁰ The clinics are currently mandated to provide voluntary HIV tests, pre- and post-HIV test counseling and regular HIV prevention seminars, in addition to testing for other STDs. Testimony gathered by Human Rights Watch, however, suggests that some sex workers were not giving their informed consent for HIV testing, making the tests de facto mandatory in violation of Philippine law.

Clara S., nineteen, told Human Rights Watch she had been a dancer at an entertainment establishment in Angeles City for four months. She described the treatment she received at the social hygiene clinic as follows.

They have me spread my legs, and they use cotton to get a sample. My friends and I never know if we’ve passed the tests or not. The nurses walk around and write down the results, but we never find out. . . . Once they told me I failed the test because I was having too much sex. All they said was that sex wasn’t good for me, because I was having too much of it. They didn’t tell me what disease I had.¹⁹¹

Twenty-seven-year-old Rosie P., a sex worker in Angeles City, said that she opted for regular HIV testing in addition to required STD tests because she “wanted to know” if she was HIV-positive. Still, she could not answer basic questions about HIV transmission.

I know that HIV starts as tulo, and then when it gets bad it becomes AIDS. . . . The last time I was tested for HIV was in 2003. They didn’t tell me anything about AIDS, because I was [HIV]-negative. Nothing. All I know is that they drew blood from my arm. Sometimes they go to the bar and do tests there. They draw blood from all the girls in the bar.¹⁹²

Jericho M., twenty-four, a registered sex worker in Angeles City, gave a similar account.

I don’t know anything about AIDS. All I know about is syphilis. . . . My last HIV test was in 2003. They told me I was getting an HIV test. They said that first HIV shows up as syphilis, and it could be up to four years before you find out if you have AIDS.¹⁹³

Testimony from Diane R., nineteen, suggested that some sex workers may not have been giving their informed consent to HIV tests administered in social hygiene clinics. A registered sex worker for eleven months, Diane R. was under the impression her HIV tests were required.

I get tested for HIV once a year. When I come to renew my license, I get tested. It’s required. The health clinic told me that, and the place where I work tells me that. I do it because I really need my license. Without it, I can’t work. I wouldn’t do it if I didn’t have to. I don’t know why. I only get blood tests if I really need to get them done.¹⁹⁴

In Quezon City, the manager of a gay bar told Human Rights Watch that the Quezon City health department conducted annual mandatory HIV tests of all of the sex workers in the bar.

Once a year, the health department requires a blood extraction for HIV. The health department asked the permission of the bar owner to do the antibody testing. The owner said OK, because they brought a letter from the federal Department of Health. . . . The last time was September 2003. They only tested the sex workers, not the dancers or the receptionist. They tested over twenty people.¹⁹⁵

The manager added that the sex workers never received the results of their HIV tests. “The health office came back after one month,” he said, “but by the time they came back, the claim stubs for the results were almost all lost, so no one claimed their result.”

Human Rights Watch asked Dr. Celia Flor Brillantes, chief of the social hygiene clinic in Baguio City, how her clinic ensured that sex workers gave full and informed consent to HIV testing. Brillantes said that because of the success of their information and education campaigns, 100 percent of the clinic’s patients wanted HIV tests. “We try as much as much as possible to have them understand they need to be tested,” she said. Her response also suggested, however, that informed consent was not something the clinic took seriously.

Perhaps some think it’s mandatory, because sometimes it’s automatic. . . If the women start refusing tests, perhaps we would see ourselves as a failure in not making them understand the importance of the test. It’s all we’re asking of them, we’re not asking that much. And besides, it won’t hurt them so much. It’s just a prick of a needle.¹⁹⁶

HIV testing without informed consent is a violation of Philippine law as well as international public health and human rights standards.¹⁹⁷ Just as important, testing without informed consent may deter people who do not want HIV tests from seeking routine health care. Sex workers who think that attending to a health clinic will result in an involuntary HIV test may sooner not attend a clinic at all—thus being deprived of vital HIV prevention services and even primary medical care. Social hygiene clinics in the Philippines should review their policies in HIV testing to ensure that patients are fully apprised of their option to refuse HIV tests, in accordance with national and international law.

Towards reform of social hygiene clinics

Health experts interviewed by Human Rights Watch identified a number of problems with using a system of social hygiene clinics to prevent HIV/AIDS and other STDs among sex workers. Chief among them was that the clinics functioned more as an employment screening process than as a genuine health service. “The clinics should provide a more honest to goodness testing and treatment for STDs, rather than just a clearance to work in sex establishments,” said Dr. Corazon Manoloto, a public health adviser for USAID.¹⁹⁸ Other experts said that police sometimes used the mandatory testing system as a pretext for harassing sex workers whose tests were not up to date.¹⁹⁹ As a substitute, experts suggested that the government provide confidential STD testing and information through a network of mobile clinics and NGO outreach workers.

Social hygiene clinics also fueled the stereotype that sex workers were an unsanitary population that needed to be kept clean for their customers, experts said. “Even the term ‘social hygiene clinic’ itself is so repulsive,” said Dr. Michael Tan. “It’s all about keeping the sex workers clean for the men.”²⁰⁰ This approach also created a false sense of security among clients. “Because the pink card is stamped, clients think, ‘I’m OK’,” said Carmina Aquino, director of the USAID-funded ASEP program. “It makes women responsible for protecting their customers, when it’s not their responsibility.”²⁰¹ To remedy this problem, one social hygiene clinic in Angeles City had renamed itself the “reproductive health and wellness” center and begun to target populations other than sex workers.

Finally, by targeting establishment-based sex workers for mandatory STD testing, social hygiene clinics inadvertently discouraged others in the community—including freelance sex workers—from seeking health services. Social hygiene clinics are overwhelmingly frequented by sex workers and are typically located in the heart of red-light districts. “The clinics reinforce the idea that the only population that needs HIV testing is registered sex workers,” said Tan. Manoloto noted that freelance sex workers, while allowed in the clinics, might stay away for fear of arrest, inferior treatment, or simply because “the clinic has been branded as being for registered sex workers.”