Atrocity in the Philippines: How Rodrigo Duterte’s War on Drug Users May Exacerbate the Burgeoning HIV Epidemic

In this issue of JAIDS, Verdery and colleagues report a social network study of persons who inject drugs (PWID) in two cities in the Philippines. In Cebu, where rates of HIV among PWID have risen rapidly in recent years, the needle sharing networks uncovered through respondent-driven sampling had a higher level of clustering than in Mandaue, where HIV spread more slowly.¹ Since the characteristics of the study participants in the two cities were otherwise similar, including comparable levels of dyadic co-injecting, the authors concluded that higher levels of clustering may explain the more rapid spread of HIV in Cebu. These findings and their implications for HIV prevention require interpretation in a broader sociopolitical context because the welfare of PWID in the Philippines has deteriorated substantially since this study was conducted in 2013. Philippine president Rodrigo Duterte, elected in 2016, openly advocates killing people who use drugs, a continuation of a war on drug users he embraced as Mayor of Davao City. We consider how Duterte’s war on drug users may affect the country’s HIV epidemic.

Overall HIV prevalence in the Philippines is low, and until recently, most infections occurred in heterosexuals and persons who engage in transactional sex. However, from 2007 to 2016, the annual number of new diagnoses increased >20-fold, and HIV incidence shifted to men who have sex with men and PWID. ² Prior to 2010, fewer than 5 HIV cases per year were reported in PWID. ² In 2007, sentinel surveillance demonstrated 0.4% prevalence among PWID in Cebu, which rose to 52.3% by 2013.³ The rapid rise of HIV among PWID has been attributed in part to shooting galleries, communal injection spaces where injection equipment is often shared. These are common in the Philippines – approximately 80% of subjects in the Verdery study reported using them – as in other Asian countries where HIV has spread quickly. Additionally, one of the most commonly used drugs in the Philippines is methamphetamine (shabu),^4,5 which is strongly associated with high risk sexual behavior and HIV acquisition.^6–8 Compounding these risks, evidence-based HIV prevention services are not widely available in the Philippines. Condom distribution is restricted,^9,10 and except for a pilot project in Cebu city, syringe exchange programs have not been implemented.³

The Philippine Drug Enforcement Agency estimated in 2015 that 1.8 million people were using illicit drugs. The currently available drug treatment facilities do not have sufficient capacity to treat the many thousands of persons who have come forward seeking drug treatment since Duterte’s election. More than 7000 persons have been killed in the Philippine Drug War to date,¹¹ and President Duterte said that he would be “happy to slaughter” three million. He has stated that children killed are “collateral damage,” that police and the military can exert extrajudicial killings without liability, and has even urged Filipino citizens to kill suspected drug users, emboldening vigilantes.¹¹ In response to journalists and human rights advocates who have challenged him, he has warned that they, too, may end up on his “watch list”.

Will Duterte’s drug war help or hinder the Philippines’ HIV epidemic? Examples from other countries clearly show that punitive approaches not only fail to prevent drug use, but further marginalize already vulnerable PWID, limiting their ability to access HIV prevention and care.¹² In Thailand, for example, a “war on drugs” that resulted in thousands of extrajudicial killings drove drug use further underground and impaired HIV prevention and care efforts for years.¹³ In Canada, Mexico, and Ukraine, police crackdowns on drug users are major drivers of HIV risk,^14–17 and may disperse HIV, sparking new epidemics. ^15,16 Together, macro-level factors such as national drug enforcement policies and micro-level factors such as police mistreatment and confiscation of sterile syringes may prevent PWID from accessing HIV prevention and care.¹⁸ In contrast to law-enforcement-based approaches to drug use, public health approaches that aim to minimize the health consequences of drug use as a central goal, such as those adopted by Portugal, the Netherlands, and Australia, can reduce the numbers of new HIV infections and improve HIV-related health outcomes among PWID.^12,19,20

What are the implications of Verdery and colleagues’ finding that higher clustering of co-injection networks was associated with faster epidemic spread? First, it bears stating that until drug users can freely access HIV prevention and treatment without fearing for their lives, HIV prevention and care interventions for PWID cannot be expected to work. In environments less hostile than the current one in the Philippines, respondent-driven sampling approaches can be translated into peer-led interventions for PWID and other hard-to-reach populations. A cluster randomized trial from Ukraine demonstrated that a peer-led social network intervention offering HIV risk reduction education significantly decreased HIV incidence compared to individual counseling and testing.²¹ In Los Angeles, health department investigators used an incentivized peer referral approach to find marginalized out-of-care PLWH, nearly half of whom were PWID, and relink them to HIV care.²²

More broadly, we need novel approaches to delivering HIV prevention and care services to PWID. Ideally these should be integrated with the diagnosis and treatment of co-morbid conditions such as hepatitis C infection, tuberculosis, drug and alcohol use disorders, and mental illness. To be effective, such programs need to be delivered in ways that treat PWID with dignity and respect -- as people instead of ‘addicts’ or other labels that de-personalize, stigmatize, and discourage individuals from seeking help. Insofar as illicit substance use is associated with incarceration, we need to improve services for incarcerated PWID with and at risk for HIV in jails, prisons, and detention centers. In places where supervised drug consumption facilities are available, implementation research is needed to assess co-location of health services such as HIV and hepatitis C testing, linkage to care, and HIV pre-exposure prophylaxis, as well as naloxone distribution and opioid substitution therapy for those who want it.

Rodrigo Duterte’s War on Drugs is a flagrant violation of human rights. It is state-sanctioned murder of a highly marginalized and vulnerable population. Governments and organizations internationally must speak out to defend the human rights of communities in the Philippines that have no voice. In considering the findings of Verdery and colleagues, we encourage all readers to consider how life has changed for PWID in the Philippines since 2013 and how we can continue working toward health equity for PWID worldwide.