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AIDS Care, July 2005; 17(Supplement 2): S153 /S164

Exploring the realities of HIV/AIDS-related


discrimination in Manila, Philippines

N. L. ORTEGA1, B. F. BICALDO1, C. SOBRITCHEA2, & M. L. TAN2


1
Remedios AIDS Foundation, and 2University of the Philippines, Philippines

Abstract
Operating according to UNAIDS’ ‘Protocol for the Identification of Discrimination against People
Living with HIV’, this study analysed health infrastructure in Manila, Philippines and determined that
despite the existence of anti-discriminatory legislation, discrimination still occurred in practice. This
was attributed to an absence of written regulations and inadequate training among health staff.
Discrimination associated with HIV/AIDS has been found to be a hindrance to the development of
successful preventive strategies, as it discourages people living with HIV/AIDS (PLWHA) and other
people from contacting health and social services. This paper argues that if the Philippines is to
maintain its low prevalence rate of HIV (and even reduce it), the discrimination that PLWHA incur
must be addressed taking account of their human rights.

Introduction
The first case of AIDS in the Philippines was reported in 1984; by 1987 the prevalence
among female sex workers was estimated to be 1 in 1,000 (Dayrit et al., 1987; Hayes et al.,
1990). Data from behavioural surveillance in 1997/98 indicated high rates of unprotected
sex among men who have sex with men (75%) and among female sex workers (34%)
(Gacad et al., 1998). The level of high-risk exposure and the observation that nearly all
(90%) HIV cases occurred through sexual transmission (UNAIDS, 2002), suggest that the
Philippines should have a high prevalence of HIV. Anomalously, it has a relatively low
prevalence compared to its similarly exposed regional neighbours. In June 2003, nationally
reported cases totalled 1,892. Although the World Health Organization and UNAIDS
estimated cases around three times and 4.5 times greater, respectively (UNAIDS, 2002;
WHO, 2003), the discrepant estimates would nonetheless indicate a prevalence of less than
0.1% among people aged 15 to 49 (UNAIDS, 2002).
A number of explanations have been proposed for the slow progression of HIV in the
Philippines and these have generally related to differences in sexual practice (Philippines
Department of Health, 2002). However, given the high rates of other high risk behaviours,
like needle sharing among injecting drug users, this does not seem to be a complete
explanation for the difference in the trajectory of the epidemic (Amadora-Nolasco et al.,
2002).
Globally, HIV-related discrimination has been identified as a significant determinant of
the spread of HIV (Aggleton, 2002; Parker & Aggleton, 2003). Discrimination increases the

Correspondence: Ms Nenita L. Ortega, 1066 Remedios Corner, Singalong, Malate, Manila, Philippines, 1004.

ISSN 0954-0121 print/ISSN 1360-0451 online # 2005 Taylor & Francis Group Ltd
DOI: 10.1080/09540120500119833
S154 N. L. Ortega et al.

suffering and the burden of the disease of PLWHA as it violates their most basic rights
including access to treatment, the right to employment, housing, and education. This, in
turn, is likely to increase the vulnerability of others to infection, as stigma and
discrimination discourage both PLWHA and others from contacting health and social
services to seek prevention information, get tested and engage in other prevention
strategies. A failure to monitor and control HIV discrimination in the Philippines, coupled
with the presence of high levels of behavioural risk, may therefore provide an ideal
environment for future increases in the rate of infection. If the Philippines is to maintain its
low prevalence of HIV (or even reduce it), human rights violations against PLWHA must be
addressed; ensuring, among other things, fair and equitable access to care and support.
Despite the significant role of discrimination, few studies have examined HIV-related
discrimination in the Philippines. One community based survey, however, did find support
for the idea of segregating PLWHA. More than half of respondents disagreed with the
statement that ‘. . .an [HIV-] infected student who is not yet ill should be allowed to go back
to school’, and around two-thirds disapproved of an infected person being invited back to
work (Ramos-Jimenez & Lee, 2001). Other community studies have identified discrimina-
tion directed towards female sex workers, in part because they are blamed for carrying,
transmitting and spreading HIV (Law, 1998a, b; Lee, 1999; Ratliff, 1999; Tan, 1993).
A survey conducted by the Asia Pacific Network of People Living with HIV/AIDS
(APN/), looked into the experiences of HIV-related discrimination. The study was
a survey of PLWHA (n / 82) in Manila, Angeles City, Olongapo City and Bacolod City.
It found that the discrimination included testing without consent, refusal to treat,
segregation and quarantine, loss of employment, as well as harassment and ridicule
(APN/, 2003). Unfortunately, knowing the experience of discrimination from the
perspective of PLWHA does not necessarily provide information about the extent and
nature of the structural and institutional determinants of the discrimination. It is by
understanding these structural determinants that different types of intervention may be
developed to address the issue.

Methods
The study is part of a larger six-country investigation aimed at documenting the occurrence
of discrimination against PLWHA at a structural and institutional level. The study followed,
with some variation, UNAIDS’ ‘Protocol for the Identification of Discrimination against
People Living with HIV’ (the Protocol) (UNAIDS, 2000). Grounded in a human rights
approach, the Protocol provides a framework for exploring the realities of discrimination in
law, internal written policies within formal institutions and institutional practice (Reidpath
et al., 2005). Where the Protocol focuses on ten key areas of social life, with 37 situations
encompassing those areas of social life (see the opening paper by Reidpath et al., 2005) this
Issue ), due to the limitation of space, this paper focuses on only one of those key areas of
social life, namely health care. Seven situations of potential discrimination arising in health
care are explored:
1. Refusal to treat on grounds of HIV/AIDS status.
2. Different treatment on grounds of HIV/AIDS status.
3. Testing without knowledge.
4. Refusal to inform a person of the result of an HIV test.
5. Health controls, quarantine, compulsory internment and/or segregation in hospital,
clinic, nursing home, etc.
Exploring the realities of HIV/AIDS S155

6. Compulsory notification of HIV/AIDS status to sexual partner(s) and/or relative(s).


7. Non-confidentiality: supplying names of individuals found to be HIV-positive to any
other party or knowingly or negligently allowing confidential files to be consulted.

The study was based in the capital of the Philippines, Manila */chosen because of its
place in the setting of national policy */and data collection occurred between June and
August 2002.

Sample
The study involved interviews with key informants, focus group discussions with direct
witnesses and the collation of legislation and policy affecting PLWHA. Key informants were
professionals from the ten areas of social life likely to have contact with or have an effect on
the lives of PLWHA on a policy and/or practice level (e.g., legal experts, government
officials and medical personnel). Direct witnesses were the people living with HIV/AIDS
who were in a position to witness directly the effect of legislation, policy or organizational
behaviour on their own lives and the lives of their friends and their family. Following the
approach suggested in the Protocol, the identification of legislation, institutional policy or
regulations and key informant and direct witnesses was based on the professional network
of the research team and members of the advisory board.
A total of 80 key informants were recruited through snowball sampling across the
professional networks of the investigators. Key informants were identified by members of
the research team using several convergent criteria: extensive work experience in the area,
substantial knowledge of institutional policies and possible frequent contact with PLWHA.
The key informants had between three and 20 years experience in the sector. The issues of
confidentiality and key informant availability required that all key informant interviews were
conducted one-to-one. The precise content of each interview was in part dependent on the
area and extent of the interviewee’s expertise in relation to the research topic.
Three focus group discussions (FGD) were held with a total of 18 direct witnesses
identified through the networks of the Pinoy Plus Association, the country’s largest and
most organized group of PLWHA. FGDs were employed rather than individual interviews
on the advice of Pinoy Plus, because many of the discriminations experienced by PLWHA
would in fact overlap and FGDs were likely to be a more effective means of data collection
given the time and resource constraints.
The sampling of legislation and policy1 was devolved to individual team members. There
was no single uniform strategy and each member of the research team was given a free hand
to collect and review as many relevant documents as possible. The reference period for the
study (i.e., the historical period over which legislation and policy was reviewed) was from
1998 to 2002. This gave priority to documents that were published and cases that occurred
after the 1998 enactment of the national AIDS Law. However, only policies and internal
procedures that were being enforced during the time of the study were reviewed. Where it
was useful to show the persistence of some discriminatory acts, despite changes in specific
cases, legislation and/or policy from prior to 1998 has been included.

Procedure
The study was led by a team at the Remedios AIDS Foundation, with technical support
from researchers at the University of the Philippines and six multidisciplinary investigators
selected because of their expertise across the ten key areas of social life covered by the
S156 N. L. Ortega et al.

Protocol. Their expertise included health policy, AIDS activism and law; many investigators
had also been involved in the drafting of the Philippine’s AIDS Law and in the work of the
Philippines National AIDS Council. To assist the identification of appropriate key
informants to interview, an advisory board was formed drawing on people from UNAIDS,
the Philippines National AIDS Council, the Department of Justice, Pinoy Plus Association,
Remedios AIDS Foundation and the Positive Action Foundation. This drew together
people from backgrounds in HIV/AIDS, PLWHA, people with legal and health knowledge,
government and NGOs.
The FGDs with the direct witnesses and the interviews with key informants were semi-
structured using the protocol and the 37 situations listed in it as a guiding framework
(UNAIDS, 2000). A training workshop was held for the investigators that focused on the
development of individual interrogative styles for interviews that maintained rapport but
permitted the solicitation of information and probing questions for clarification. For the
reasons outlined earlier, all key informant interviews were conducted one-to-one whereas
all direct witness interviews were conducted in focus groups. Interviews and FGDs were
recorded as field notes. Specific quotes were recorded verbatim.
Participation in the study was strictly voluntary. Health Action Information Network, an
NGO with an extensive experience in the area of health and development research, did a
review and evaluation of the proposal and the entire initiative, including the UNAIDS
Protocol. The proposal and the Protocol that were used in the research were also reviewed
by the advisory board and independently reviewed by the Deakin University Human
Research Ethics Committee.
After the data were collected, instances of potential discrimination were discussed by the
research team to determine if the discrimination was ‘legitimate’ (i.e., justified) or
‘arbitrary’ in nature. The specific criteria for deciding whether instances of discrimination
were justified are described more fully elsewhere (Reidpath et al., 2005; UNAIDS, 2000)in
this Issue .

Results
The results of the study of HIV-related discrimination in the area of health will be presented
first with respect to legislation, then policy and finally practice.

Legislation
In the Philippines there is one single overriding piece of legislation covering HIV/AIDS, the
Republic Act 8504 (RA8504), otherwise known as the ‘National AIDS Prevention and
Control Act of 1998’. This legislation guarantees the rights of PLWHA and provides
protection against arbitrary discrimination. It protects against mandatory testing, unin-
formed consent and breaches of confidentiality by health personnel. The Act also
guarantees the availability of HIV testing in many health centres, clinics, blood banks
and laboratories, as well as making testing free of charge. Free pre- and post-test counselling
is also prescribed by the Act.
In the declaration of general policy, Section 3(b) makes general statements about the
treatment of PLWHA:
1. Compulsory HIV testing shall be considered unlawful unless otherwise provided in
this Act.
2. The right to privacy of individuals with HIV/AIDS shall be guaranteed.
Exploring the realities of HIV/AIDS S157

3. Discrimination, in all its forms and subtleties, against individuals with HIV/AIDS or
persons perceived or suspected of having HIV/AIDS shall be considered inimical to
individual and national interest.
4. Provision of basic health and social services for individuals with HIV/AIDS shall be
assured.

The application of RA8504 to each of the seven health care situations will be discussed in
turn.

Situation 1: Refusal to treat on grounds of HIV/AIDS status. Section 51 of the Act deals with
hospital and health care based discrimination. It explicitly addresses and prohibits refusal to
treat or, in the words of the Act, ‘denial of access’ and this is the case whether a person’s
HIV status is known, suspected or perceived.

Situation 2: Different treatment on grounds of HIV/AIDS status. Section 51 also deals with
different treatment according to HIV status. It states, in part, that ‘. . .Access to health
services must be on an equal basis for all people’ and that the fees charged must be the same
for all patients, irrespective of HIV sero-status.

Situation 3: Testing without knowledge. Testing without knowledge is explicitly prohibited


under the Act, and testing now requires ‘written informed consent’ (S.26). An exception to
this is in the case of unlinked and voluntary anonymous testing (S.29).

Situation 4: Refusal to inform a person of the result of an HIV test. Section 31 of the Act requires
all those offering HIV testing to provide, free of charge, pre- and post-test counselling. The
provision of post-test counselling necessarily requires that the person who is tested be
informed of his or her HIV status.

Situation 5: Health controls, quarantine, compulsory internment and/or segregation. There is no


provision for quarantine, isolation or internment of PLWHA. The only discussion of
quarantine and isolation in RA8504 relates to restrictions on travel (S.48) and that is in the
context of denying it permissibility.
The equal treatment provision in Section 51 for PLWHA (or those suspected of being
HIV-positive) does not explicitly address isolation or quarantine, but it does indicate that it
is not permitted.

Situation 6: Compulsory notification of HIV/AIDS status to sexual partner(s) and/or relative(s).


Section 45 holds that ‘[a]ny person with HIV shall be obligated to disclose his/her HIV
status and health condition to his/her spouse or sexual partner at the earliest opportune
time’.

Situation 7: Non-confidentiality. Section 41 provides for strict confidentiality in dealing with


the records of HIV PLWHA. It covers written records and covers ‘. . .all forms of
communication that directly or indirectly lead to the disclosure of information on the
identity or health status of any person who undergoes HIV testing’.
There are exceptions to the confidentiality provisions (see S.42). These include legal
proceedings that relate directly to the HIV status of an individual and fulfill reporting
requirements for the State monitoring of HIV (AIDSWATCH).
S158 N. L. Ortega et al.

Written policy within formal institutions


The Philippines health care services are divided into two streams, government-funded
services and private user-paid services, both are subject to the ruling of RA8504 and these
will be discussed separately.

Government hospitals. All three national level government hospitals under review had
introduced non-discriminatory, internal, written regulations that complied with RA8504.
The internal regulation developed by one of these hospitals was regarded by the
Department of Health as a model for treatment of HIV/AIDS cases. The regulations
presented easy to follow flow-charts for the management of both inpatient and outpatient
HIV/AIDS cases and included step-by-step procedures for HIV antibody testing, counsel-
ling, medical management and referral.
The investigator for the area was allowed to read through these written regulations, on
condition that:
1. The documents were not removed from the premises.
2. Notes would not contain direct quotes from the documents.
3. The notes would not be quoted in any publications from the study.

The notes were, thus, used as data in later discussions with the entire research team, when it
was determined that the regulations showed no arbitrary discrimination. In presenting
results, however, reporting is restricted to a high level of generality.
A failure to identify HIV-related discrimination does not show that all government
hospitals have uniformly adopted anti-discrimination regulations confirming with RA8504.
Two Key Informants (five and six), medical doctors from the Department of Health (DoH)
in metropolitan Manila, indicated that, at the time of the interviews, no written anti-
discrimination regulations existed in the DoH for patients infected with HIV/AIDS.
Testimony by a number of the direct witnesses, who had previously been patients in other
government hospitals within Manila, also confirmed that such regulations did not exist in
the government health facilities where they were being treated. In the absence of anti-
discrimination procedures and regulations for treating HIV-positive patients, key infor-
mants five and six explained that the general standard of precautions (i.e., universal
precautions) was followed by all medical personnel when treating HIV/AIDS patients in the
DoH in metropolitan Manila */as will be discussed later, however, their use of universal
precautions did not accord with the general understanding.

Private hospitals and other private health facilities. None of the private health facilities under
review had any written internal regulations regarding AIDS. For instance, in the Obstetrics
and Gynecology (OB-GYN) department of one tertiary level private hospital, a key
informant (ID2), who was a senior OB-GYN specialist, indicated that clinicians had not yet
received training on HIV/AIDS case management. ID2 was also unaware of any policies
(including specific anti-discrimination policies) or procedures related to the management
and care of patients with HIV/AIDS. Similar situations were reported by other key
informants working in smaller (secondary and primary) private health facilities. The key
informants noted that, in the absence of HIV/AIDS specific regulations and procedures, all
medical staff followed universal precautions ‘whenever there was a ‘‘probable or suspected
case’’ of HIV/AIDS’.
It became apparent that the absence of appropriate internal regulations in the private
health sector was, at least in part, due to the lack of awareness by the administrators of
Exploring the realities of HIV/AIDS S159

their institutional obligations under the RA8504. In fact, none of the key informants in
the private health sectors have even heard of the National AIDS Prevention and Control
Act. However, regardless of the structural reasons for the failure of the private health
sector to carry out their legal obligations under RA8504, the research team reached
the conclusion that the continued absence of clear-cut PLWHA-sensitive policies increased
patients’ vulnerability to discriminatory practices by staff at such health facilities. Thus,
the absence of appropriate internal regulations and procedures could legitimately be
considered discrimination ‘by omission’ for all seven situations under the health care
area.

Institutional practice
It is in the area of unwritten policy and practices that PLWHA most directly experience
HIV-related discrimination. Discrimination will be discussed for each of the seven health
situations separately.

Situation 1: Refusal to treat on grounds of HIV/AIDS status. Four instances were identified
where a PLWHA was refused treatment and the research team ultimately determined
that the discrimination was arbitrary in each case. In 2000, for example, one direct witness
attended a government National Hospital for a skin biopsy. The attending dermatologist
refused to conduct the biopsy because of the direct witnesse’s HIV status. A more common
form of refusal was the denial of pre- and post-test counselling, even though this is explicitly
required under RA8504. Another direct witness (ID86) was tested without counselling,
following a series of visits to a hospital for treatment, which did not result in any
improvement in his condition. The results of the test showed that ID86 was HIV-positive
and when he asked for counselling, the doctor responded, ‘We do not have that kind
of service here in our hospital. You have to find it on your own.’ No psychological support
was provided and no referral. A third direct witness recounted a similar experience in
1999, when he was tested without prior counselling and the results were provided,
summarily and without explanation or support, to the Direct Witness and his sister at the
same time.

Situation 2: Different treatment on grounds of HIV/AIDS status. Two cases of arbitrary


discrimination that occurred within the reference period were identified for this situation.
Other cases were identified that had occurred prior to 1998, which were excluded from the
data. Strikingly, however, the forms of discrimination before and after the beginning of the
reference period were similar, suggesting that little has changed since the introduction of
RA8504. A number of key informants denied the occurrence of this form of discrimination
in their institutions. One physician (ID3), for instance, who worked at a local government-
funded health centre, insisted that medical staff at the centre treated all patients the same
regardless of HIV status. The experience of direct witnesses, however, indicated that equal
treatment was not a universal experience. In May 1999, recalled one direct witness (ID3),
she was at a national government hospital for a caesarean delivery. ‘Every morning, the
nurses would make rounds and would say to me. ‘‘So you’re HIV-positive? Why did you still
decide to get pregnant?’’’ And this was said loudly enough for other patients to hear.
Another direct witness (ID93), attending the same national government hospital in 2001,
described her treatment while hospitalized for surgery for breast cancer. ‘The medical staff
placed a huge. . .sign over my bed [that] read ‘‘Universal Precaution’’.’ Contrary to the
intention of the universal precautions, which is to be applied to all patients, here it was
S160 N. L. Ortega et al.

reserved only for patients with HIV/AIDS. The experience highlights a common form of
discrimination by many hospitals in the Philippines involving the re-interpretation of what is
otherwise intended as a protective policy but when applied selectively results in
discrimination against HIV-positive patients. Direct witness ID93 also found that hospital
staffs were avoiding contact with her in other ways. Her food was provided in a plastic bag,
rather than on a tray. They would avoid taking her temperature with a thermometer and if
staff wanted to communicate with her, they would shout at her from the door.

Situation 3: Testing without knowledge. The three earlier instances of a failure to provide pre-
and post- test counselling are also instances of ‘testing without knowledge’. In the
Philippines, knowledge about HIV/AIDS is not high (Balk et al., 1997; Morisky et al.,
2004) and there is a culture of patients completely trusting medical doctors. It is unusual,
therefore, for a patient to question his/her doctor in matters of diagnosis and treatment.
From the data, it appears that where an HIV test is concerned, it is left to the doctor to
explain to the patient what is involved, rather than */as prescribed in the Act */
appropriately trained counsellors. However, merely informing a patient that an HIV test
is to be conducted is not enough, because many direct witnesses do not have the necessary
knowledge and would not actively seek information from their doctors prior to undergoing
the test. For direct witnesses who had applied for jobs overseas, this was particularly
pertinent, because they had to undergo an HIV test as a condition of their job application.
Key informant data confirmed that often the HIV test is ‘hidden’ amongst a list of health
checks. Under these circumstances, it is difficult to argue that the patients have any ‘true’
knowledge about being tested.

Situation 4: Refusal to inform a person of the result of an HIV result. Two direct witnesses
experienced a refusal to inform them of the results after undergoing HIV tests. In both
cases, the test was conducted as part of their applications for employment overseas. The
private clinics/laboratories that had performed the tests not only refused to inform the direct
witnesses of their test result, they also passed the results directly on to the recruitment
agencies.

Situation 5: Health controls, quarantine, compulsory internment and/or segregation. No cases of


discrimination were found relating to matters of quarantine, segregation or compulsory
internment. But in death certificates, cause of death (AIDS) is reflected clearly. In one
national government hospital, cadavers of people who died with AIDS are not allowed to
stay at the hospital’s morgue for more than 12 hours. They usually transfer and remove that
cadaver to a private mortuary without the consent and knowledge of the bereaved family
and that cadaver, in turn, is automatically hermetically sealed by the funeral parlour. When
asked why they perform such practice of sealing, they would say that the cadaver has AIDS
and that it is highly communicable. There were several occasions when families were told to
bury the cadaver within 48 hours without embalming, that it could not be put on public
view and could not be visited and seen by children.

Situation 6: Compulsory notification of HIV/AIDS status to sexual partner(s) and/or relative(s).


Key informant interviews indicated that compulsory notification of HIV/AIDS status to
sexual partner(s) and/or relative(s) was neither policy nor practice within the facilities where
they worked. This was supported by data from direct witnesses none of whom had been
subjected to compulsory notification.
Exploring the realities of HIV/AIDS S161

In fact, a majority of the direct witnesses regarded the notification of their sexual
partner(s) as a fundamental right of their partners. These Direct Witnesses thus considered
the omission of such a policy as a violation of the rights of their partner(s). They did,
however, identify the failure of the medical staff to support them in the process of informing
their partners as a significant issue. One direct witness observed:

. . .The doctor was just very insensitive. She was insisting that I should inform my wife
about my status. . . .I asked her if she could help me talk to my wife. I said I would take my
wife to her office then she could explain everything. The doctor, however, refused. ‘You’ll
bring her here? What if she gets hysterical!’ she said. I explained to her that that was
exactly the reason why I was seeking her help. But she was adamant. She just referred us
to another government institution (ID89).

Situation 7: Non-confidentiality. Four cases that breached confidentiality were identified.


The cases involved either a breach of confidentiality within a health care facility or the
release of patient information to an employment agent.
In one instance, a doctor discussed a patient’s HIV status openly in the corridors of the
hospital ‘. . .in front of many people. I was not able to do anything but run, hide in a room,
and cry’ (DW84). Another direct the witness described his doctor telephoning a colleague
about his case, while standing at the nurses’ station:

She [the doctor] said loudly: ‘This is regarding an AIDS patient. . .’ Everybody in the
place heard her and looked at me from head to toe. I really felt embarrassed. I had no idea
what they were thinking of me (ID89).

The third instance described by a direct witness related to the display of the ‘universal
precautions’ sign, prominently identifying the direct witness, at least to other health care
staff, as an HIV-positive patient.
The revelation of a direct witness’s HIV status to an employment agent was another
breach of confidentiality. ‘I went back to the doctor and asked him to explain such a breach
of confidentiality. . .. He denied that the laboratory had anything to do with the spill of such
news to the agency’ (ID87).

Discussion
The overall findings of the study show that discrimination occurs mostly in practice rather
than on the levels of legislation and policy. The absence of discrimination at the legislative
level is largely due to the introduction of the National AIDS Law, which is clearly an
important positive step towards protecting the rights to non-discrimination for PLWHA.
However, the establishment of protective law alone is insufficient as a national response.
Furthermore, the absence of identified instances of discrimination on the institutional level
does not mean that discrimination does not exist; rather, it probably reflects an absence of
written regulations in many of the hospitals under study. Despite the limitations in terms of
the number of key informants sampled, the data reveals that this is particularly problematic
in the practice of private hospitals. Here, not only did the hospitals appear to have failed to
integrate RA8504 into their internal regulations, but key informants working in those
hospitals appeared to be completely unaware of the legislation and their obligations under
it. This highlights the fact that the establishment of the law without adequate investment in
S162 N. L. Ortega et al.

education and enforcement is insufficient to achieve real change. The failure of private
health care settings to adopt appropriate internal policies conforming to RA8504 creates
serious opportunities for discrimination against PLWHA.
PLWHA continue to suffer severely from discrimination at the hands of health care
providers. Many of the direct witnesses reported severe stress because of the lack of pre- and
post-test counselling; while others were subjected to acts of discrimination and non-
confidentiality due to the personal prejudice and/or carelessness of the health care
providers, and/or the failure to apply universal precautions in a truly universal fashion.
The unavailability of pre-test counselling services at the health services that were contacted
is particularly problematic as it creates a situation in which patients who are not equipped
with the necessary knowledge to give true consent are being tested. In addition, the absence
of post-test counselling service leaves patients ill equipped for dealing with their positive test
results. Such discriminatory practice appears, unfortunately, to be commonplace, even in
government hospitals where adequate written regulations are already in place.
All of these findings highlight the need for improving the ethical standards and the skills
of health workers to deal with HIV/AIDS-related issues, as well as providing effective
treatment, care and support services within the health care system to properly look after
PLWHA. The integration of protective law into the form of written regulations alone is
inadequate and will not address the problem in practice.
The full reach of the findings, however, need to be tempered with an understanding of
some of the limitations of the study. More general limitations of the Protocol are discussed
elsewhere (Chan & Reidpath, 2005) in this Issue . A significant limitation of the study,
however, is (by design) the focus on a single city */in this case, Manila. Although one might
suspect that the types of concerns identified in Manila would also be found elsewhere in the
Philippines, that remains to be investigated. Indeed, the raison d’être of the Protocol is
precisely this kind of comparison between locations, and within locations over time. Other
limitations to the generality of the findings arise from the approach to the sampling of
legislation and policy, as well as key informants and direct witnesses, and this could be
improved in future iterations of this study.
Notwithstanding any limitations, the results support the general view that the full
realization of human rights is an essential element in combating the HIV/AIDS pandemic.
It reduces the suffering of those who are living with the disease, as well as the vulnerability
of the population. The facilitation of a social and political environment that supports non-
discrimination is of particular importance if the rights of PLWHA to care, support and
treatment are to be fully realized.
This study, building on previous research in the area, aimed to document the occurrences
of arbitrary and legitimate forms of discrimination against PLWHA. The findings indicate
that despite legislative policy barring discrimination against PLWHA, in practice,
discrimination continued to occur and shows a need for better integration of legislation
with policy and practice. The current gap allows for arbitrary forms of discrimination to be
directed against PLWHA, which have not only a damaging effect on their lives, but hinder
the development of successful preventive strategies.

Acknowledgements
This research was part of a grant made by Ford Foundation to Deakin University for
‘A situational analysis of HIV/AIDS-related stigma and discrimination in the Asia Pacific’.
The Philippines was one of those six countries covered by this initiative. For their help and
assistance we would like to thank Dr Daniel Reidpath and Ms Kit Yee Chan (Deakin
Exploring the realities of HIV/AIDS S163

University), Dr Lisa Messersmith (Ford Foundation). In the Philippines, this research was
taken on by the Remedios AIDS Foundation, supported by a Technical Advisory Board,
Pinoy Plus Association and some government agencies. We also would like to express our
gratitude to all the investigators, all the people who had been involved. The investigators on
the study included: Atty Rosalina Aquino, Atty Glenda Litong, Ms. Merceditas B. Apilado,
Ms. Racquel Shokouhi, Ms Liza Fetalino, Mr Adonis Sucalit, Ms Nenita L. Ortega and Mr
Benjamin Franklin Bicaldo.

Note
1 As much as possible, the translation of policy and legislation aimed to convey the sense and intent of the original,
and may not represent a strict legal translation.

References
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