Genetic subtypes of HIV-1 in the Philippines.

OBJECTIVES: To determine the genetic variability of HIV-1 amongst infected Filipinos and to analyze phylogenetic relationships, temporal introductions and transmission dynamics of identified variants. METHODS: Polymerase chain reaction amplification and direct sequencing of a 204 base-pair fragment of the env C2-V3 region from uncultured peripheral blood mononuclear cells obtained from 51 HIV-1-positive Filipinos infected from 1987 to mid-1996. Evolutionary distance and phylogenetic relationships among the DNA sequences were estimated. RESULTS: The 51 Philippine strains were classified into five env V3 subtypes, namely subtype B (n = 37), subtype E (n = 8), subtype A (n = 3), subtype C (n = 2) and subtype D (n = 1). The overall env nucleotide divergence ranged from 11.7 to 32.2%. The nucleotide variation appeared to be random and no temporal ordering was observed. The variation of the sequences at the tip of the V3 loop was very broad. Subtypes B and C isolates did not show close genetic relationship to other Asian variants. Only three of the subtype E strains had close affinity to known Asian sequences. The majority (94%) of the subjects acquired the infection by sexual transmission. About two-thirds were presumably infected outside the Philippines, whereas the remaining were infected indigenously. Information was limited to allow segregation of the identified subtypes by mode of transmission or risk groups. CONCLUSION: Our findings demonstrate the presence of multiple genetic subtypes of HIV-1 in the Philippines. The apparent geographic range of previously reported genotypes in South and South-east Asia was extended and has obvious implications for env-based antiviral interventions.

The Second National AIDS Research Forum.

PIP: On November 17-18, 1995, the Second National AIDS Research Forum was held in the Philippines to explore the theme "Responding to the HIV/AIDS Epidemic." Individual conference sessions on the first day focused on such topics as 1) national strategies in HIV/AIDS prevention, 2) experiences in HIV/AIDS prevention research, 3) ethics in HIV research, 4) the current status of the HIV/AIDS epidemic in the Western Pacific region, 5) an up-date of national HIV surveillance, 6) HIV testing in Frontline Laboratories, 7) cofactors in HIV disease progression, 8) the natural history of HIV infection in female sex workers, 9) the impact of and HIV prevention workshop for men in metro Manila, 10) targeted sexually transmitted disease (STD) interventions, and 11) an advocacy campaign on STD/HIV/AIDS for child and youth sex workers. The second day was devoted to reports on 1) fungal infections in patients, 2) diagnostic tools for pulmonary opportunistic infections, 3) the sex behavior of urban Filipino males, 4) HIV/AIDS control among women working in commercial sex establishments, 5) HIV/AIDS risk behavior and knowledge, attitudes, and beliefs among truck crews, 6) hospitality women in Davao city, and 7) the risk exposure reported by young users of the Remedios hotline. The final symposia were characterized by their attention to 1) AIDS-related conditions and STDs, 2) a clinical and microbiologic profile of tuberculosis in Filipino AIDS patients, 3) STD prevalence and behavioral correlates of STD among female sex workers, 4) a possible link between bacterial vaginosis and HIV, 5) living with AIDS, 6) coping mechanisms of households affected with HIV/AIDS, and 7) a nongovernmental organization's response to HIV prevention.^ieng

Results of a model AIDS prevention program for high school students in the Philippines.

OBJECTIVES: To describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students' AIDS-related knowledge, attitudes and AIDS-preventive behaviors. SUBJECTS AND METHODS: A cluster-randomized, controlled trial with pretest/post-test evaluation was conducted in four demographically similar public high schools in a semi-urban district of Metro Manila, the Philippines. Of 845 high school students who participated in the baseline survey, 804 (95%) completed a postintervention questionnaire. INTERVENTION: An AIDS prevention program was developed by public high school teachers together with local AIDS experts, social scientists and health educators. The teacher-led AIDS program was designed to provide students with accurate information about AIDS, particularly in dispelling misconceptions about casual contagion, to foster positive attitudes towards people with AIDS and to develop skills aimed at clarifying values and assessing intended behavior. RESULTS: At baseline, 11% of students (20% of males and 4% of females) reported ever having had sexual intercourse (mean age 14 years). Among these, condom use was low (24%). After implementation of the AIDS prevention program, statistically significant effects favoring the intervention group were observed in knowledge and attitudes towards people with AIDS. While there was no statistically significant overall effect on intended preventive behavior, the program appeared to delay the students' intended onset of sexual activity. CONCLUSIONS: A sizable number of Filipino high school students are sexually active but condom use is low. School-based AIDS prevention programs can be developed and implemented in developing countries with the assistance of school personnel to address sexual issues. Our program was successful in increasing AIDS-related knowledge and improving attitudes towards people with AIDS. Supplementation with other preventive activities may be needed to achieve lasting changes in students' risk-taking behavior.

PIP: The objectives were to describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students' AIDS-related knowledge, attitudes and AIDS-preventive behaviors by means of self-administered questionnaires. A cluster-randomized, controlled trial with pretest/post-test evaluation was conducted in 4 demographically similar public high schools in a semi-urban district of Metro Manila, the Philippines. Of 845 high school students who participated in the baseline survey, 804 (95%) completed a postintervention questionnaire. An AIDS prevention program was developed by public high school teachers together with local AIDS experts, social scientists, and health educators to provide students with accurate information about AIDS, dispel misconceptions about casual contagion, to foster positive attitudes towards people with AIDS, and to develop skills aimed at assessing intended behavior. At baseline, 80 (11%) of 804 students reported ever having had sexual intercourse (mean age 14 years). 66 were male and 14 were female (p 0.001). Among these, condom use was low (24%). Reasons for failure to use condoms were: use of other method (26%) and loss of sensitivity (25%). After implementation of the AIDS prevention program, the intervention group was more likely to answer correctly that HIV cannot be transmitted by mosquito bites (p 0.01), through a cough or sneeze (p 0.01), or by shaking hands with an infected person (p 0.01). Students who had attended the AIDS education program were less likely to avoid people with AIDS and were more compassionate toward them (p = 0.01). Changes in knowledge about modes of HIV transmission were associated with improvements in preventive knowledge (p 0.001). While there was no statistically significant overall effect on intended preventive behavior, the program appeared to delay the students' intended onset of sexual activity. The program was successful in increasing AIDS-related knowledge and improving attitudes toward people with AIDS.

HIV-1 variants in South and South-East Asia.

HIV spread in South and South-East Asia is most alarming, and genetic variability of HIV-1 is an important consideration in vaccine development. In this study, we examined the third variable (V3) region of env gene of HIV-1 variants prevalent in Thailand, Malaysia, India, and the Philippines. By phylogenetic tree analyses, an HIV-1 variant from an injecting drug user (IDU) in Thailand belonged to subtype B, and HIV-1 variants from 2 IDUs in Malaysia were classified into 2 subtypes, B and E. One HIV-1 variant from a male homosexual in the Philippines belonged to subtype B. Out of 8 HIV-1 variants from sexually transmitted disease patients in India, 7 belonged to subtype C, and one to subtype A. Although the total number of individuals examined in this study was limited, 4 HIV-1 subtypes were found in South and South-East Asia and large international movements of HIV-1-infected individuals in this region could induce global dissemination of these HIV-1 variants.

AIDS education for hospital workers in Manila: effects on knowledge, attitudes, and infection control practices.

OBJECTIVE: To evaluate an AIDS education intervention for health workers in Metro Manila hospitals. METHODS: A randomized controlled education program consisting of lectures, role-plays, posters and pamphlets was delivered to physicians, nurses, laboratory technologists and orderlies in Manila hospitals. Knowledge, attitudes and infection control practices were measured before, immediately after, and 2 months after the intervention. RESULTS: Baseline survey among 641 hospital workers revealed poor knowledge, negative attitudes towards AIDS patients, and inappropriate infection control practices. Immediately after the intervention, there was significant improvement in (1) knowledge scores (8.7-11.2 in the intervention group versus 8.5-9.5 in the control group; range, 0-14), (2) attitude scores (54.4-60.6 versus 54.6-56.8; range, 22-88), and (3) needle-recapping practices (14-43% versus 39-43%) (all P values < 0.001). After 2 months, attitude scores in the experimental group fell to the same level as those of the control group, while improvements in knowledge and needle recapping were largely maintained. Role-playing was considered by the participants to be the most effective component of the intervention. CONCLUSIONS: These results suggest that AIDS training for hospital workers in the Philippines and in similar countries is necessary and can be effective. Ideally, such training should include role-playing and should be ongoing in order to sustain the effect.

Relevance of antibody content and test format in HIV testing of pooled sera.

OBJECTIVE: To determine the effects of HIV-1 antibody level and test-format characteristics on testing pooled sera. DESIGN: This study was designed with a laboratory exercise followed by test observations on serosurveillance samples. METHODS: Sera with low, medium and high (n = 22, 12 and 20, respectively) antibody titers were pooled with HIV-1-negative sera and tested with two enzyme-linked immunosorbent assays (ELISA) and a particle agglutination test. The same kits were used to test single and pooled (batches of five, 10 and 20) samples collected from 3000 blood donors and sex workers. These samples were then seeded with 50 varying antibody-containing sera and similarly tested. Initial reactivities, sensitivities, and specificities for all test kits were calculated and compared. RESULTS: In the laboratory exercise, all reactive pools of five were detected. False-negative pools in batches of 10 and 20 with low antibody titers were noted with one or both ELISA, but not with the particle agglutination method. Testing 3000 samples revealed three confirmed reactive samples and 100% sensitivity/specificity for all kits, for both single and pooled sera testing. Increased initial reactivity (IR) was noted for the two ELISA. Examinations of pools of the seeded 3000 samples with the two ELISA showed false-negative reactivity with pools of 10 and 20 when pools contained low antibody sera (sensitivities and specificities of 92-97.9% and 98.1-100%, respectively). Again, increased IR was seen with the ELISA. False-negative pool and increased IR was not seen with the agglutination test (sensitivity/specificity 100%). CONCLUSIONS: We recommend the use of the particle agglutination assay for testing pooled sera of batches of 20 or less. Components of reactive pools should then be tested and reactive samples should undergo supplementary testing. Pooled samples tested by ELISA should not exceed five per batch. Retesting of reactive pools, testing of its components, and supplemental test(s) of reactive sera should then follow. The optimum pool size for most laboratories is five, with the best technical and economic performance seen with the particle agglutination assay.

Prevalent serogroups and antimicrobial susceptibility of Shigella strains in Metro Manila, 1982-1988.

From 1982 to 1988, Shigella was detected in 4% of stool specimens cultured at The Research Institute for Tropical Medicine (RITM), Manila. S. flexneri was the most prevalent serogroup with 2a, 1b and 1a as the predominant serotypes. Isolation was most frequent during the July to December period. Drug resistance was most often observed in S. flexneri with serotype 2a exhibiting resistance to the combination of ampicillin, chloramphenicol, tetracycline and streptomycin. More multiple-drug than single-drug resistant strains were observed for the last four years. Ampicillin is still the most frequently used drug for most forms of shigellosis in the Philippines. However, the demonstration of increasing resistance among the isolates studied in RITM underscores the need to monitor antibiotic susceptibility studies and document the emergence of resistant strains in the entire country.

Emerging patterns of HIV infection and control in the Philippines.

PIP: In the Philippines, a total of 46 female prostitutes were found seropositive for the antibodies of HIV as of July 31, 1987. A total of 53,376 tests were performed among these women, and repeated positive tests by enzyme-linked immunosorbent assay (ELISA) were confirmed by the Western blot test. 40 of the cases were found in the Angeles City and Olongapo areas adjacent to military bases, and they were detected from among 34,998 blood examinations, for an overall HIV antibody positivity rate of 1.1/1000. In the MetroManila area, 4 prostitutes were found positive from among 10,549 tested, yielding an antibody positivity rate of 0.4/1000. The Department of Health tested 867 male homosexuals, and found only 1 individual seropositive. 3 other infections were reported by private sources, 2 of them in male homosexuals. No infection was detected in 3200 blood donors or in 12,000 overseas workers. A total of 9 cases of AIDS were reported, and all contracted the disease abroad. 7 were Filipinos: 4 homosexual/bisexual men, 1 elderly woman got it via blood transfusion, and 2 other undisclosed persons. The Philippines AIDS control plan for the period from July 1987 to December 1990 estimated about 500 cases of HIV infection in 1987 which could progress to 150 cases of AIDS by 1992. A total of 4000 cases of HIV infection by 1990 could result in approximately 1000 cases of AIDS by 1995. The AIDS Committee projected 300 cases by 1990. The strategy of AIDS control is to block the 3 main routes of transmission: sexual activity, contaminated blood supply, and infected mother to child. Control activities concern surveillance (high-risk behavior groups during the next 3 years) and laboratory testing, education, personnel development (counseling, clinical management, research), and organization of local AIDS committees in Angeles City, Olongapo, and Manila.^ieng