Juli Generalao is a project officer for Project ROMP (Reaching Out to Most-at-Risk-Populations) in Cebu, Philippines. The project is funded by the United States Agency for International Development (USAID) and FHI 360. Project ROMP works closely with the Cebu City Health Department, Cebu Plus and other organizations to help key populations access HIV prevention, treatment and care.
How did you get involved in HIV outreach and harm reduction?
In 1995 I became a volunteer peer educator for HIV outreach in Cebu via a local nongovernmental organization called Bidlisiw, “Rays of the Morning Sun”, while I was studying for my Bachelor of Science in Mathematics. I moved to the Tropical Disease Foundation, which was the Philippines’ Principal Recipient under the Global Fund Rounds 3 and 5. Then I worked with the Philippine Department of Health as part of its size estimation programme for people who inject drugs (PWID) in the Cebu Tricities area.
What’s the main focus of Project ROMP?
Our project clearly acknowledges that the PWID needs to be addressed strategically and with compassion. Strategically because unless you are grounded in reality and adopt practical ways to reduce harm among this highly vulnerable population, HIV rates will skyrocket even further and ultimately impact wider society as well. With compassion because persons who inject drugs are human beings too, and need to be treated with understanding and respect, if they are to be encouraged to take greater responsibility for their health and adopt health-seeking behaviours. Many of them have had traumatic lives that have contributed to their habit. We need to understand the whole picture here.
ROMP is a three-year project that’s clearly shown best practices in terms of outreach and harm reduction. We are now focusing on long-term sustainability of these practices, and are trying to find ways for Local Government Units (LGUs) to absorb the work. The peer educators we have will continue their work under the LGUs.
What is the context for your work?
The injecting drug problem has been around for a long while, but it accelerated around 2003 when several HIV projects ended and outreach came to a near-halt. The 2009 Integrated HIV and Behavior Serologic Surveillance (IHBSS) in Cebu discovered that HIV PWID cases had increased substantially. The Department of Health was truly alarmed. So there was a project specific to PWID through the Global Fund, which included HIV testing and a fledgling needle and syringe programme. But there was no in-depth counselling for PWID at the time – they were tested without any significant follow-up. Project ROMP eventually filled that gap, to a large extent.
Have your efforts succeeded?
We originally focused on what we call “motivational interviewing” but we found that so many PWID continued to die, so we tweaked the approach to focus on case management, creating a matrix for a continuum of care. This has helped, but we’re still not completely there. There’s still very limited capacity at our partner hospital, a provincial-level institution. We’ve been pestering the authorities to increase capacity including installing a CD4 machine there so services for PWID can be scaled up. But CD4 testing and other HIV services are not sufficiently income-generating for hospitals, so there’s little incentive to carry these out. With this less than optimal situation there’s still a great “loss-to-follow-up” when it comes to PWID.
What does the future hold for PWID HIV prevention, treatment and care?
That’s a difficult question. I’m sometimes frustrated at how those who should know better are responding to the epidemic, especially regarding harm reduction approaches and access to treatment for our communities. We need a strategic approach. Short-term thinking will be dangerous.
There’s already a big intersection between PWID and female sex workers, and to an extent between PWID and men who have sex with men (MSM) – and this is helping spread HIV further afield. More and more cases will be detected. But budgets are being slashed. Political realities impact policy-making, leading to contradiction and confusion.
The United Nations Office on Drugs and Crime (UNODC) organized an operational planning exercise which brought all players together – the health sector, the law enforcement agencies, our community organizations. The exercise clearly showed how sound harm reduction programmes could bring down the epidemic in a relatively short span of time. But needle and syringe programmes remain illegal, even though a pilot project for Cebu was given conditional clearance. So those who provide such services were told to continue doing what they were doing, but to continue doing it discreetly.
If you know something works and saves lives, why wouldn’t you do it openly and proudly? If you could combine that approach along with a rehabilitation and detoxification program for PWID, we could have amazing results.
Is your glass half-full or half-empty?
It’s one-fourth full! There’s a huge amount of work left to do. WHO has been very supportive with its work on HIV and key populations, which in turn encourages our partners and us to carry on despite the challenges. We know we’re not alone.