Dressed in a faded T-shirt and shorts, the HIV-positive young man identified by case number KB14EPN wore a surgical mask to conceal his identity. His arms and legs were bare, revealing marks where needles had pierced his skin over the past decade.
The former real estate sales manager, now homeless and living in a temporary church-run shelter, has been receiving HIV treatment and care at Klinika Bernardo in Quezon City. His fragile condition is further compromised by a tuberculosis co-infection. His CD4 count is down to 38.
I’ve made big mistakes in my life,” KB14EPN told a group of visitors from the HIV division of the World Health Organization Regional Office for the Western Pacific. “I began using drugs, I shared needles. When I told friends about my HIV status, instead of supporting me they shunned me. My family, my own parents, have rejected me for being a drug user, for being a gay man. But I’m not alone. The people at this clinic are here for me.”
Klinika Bernardo is funded by the Quezon City Health Department. The clinic is located in the Social Hygiene Clinic and provides HIV prevention, testing and treatment services primarily to men who have sex with men (MSM) and transgender people.
“The Social Hygiene Clinic and Klinika Bernardo complement each other,” explained Dr Leonel John B. Ruiz, Medical Director at Klinika Bernardo. “From 8am to 3pm the Social Hygiene Clinic primarily sees a clientele of female sex workers, and from 3pm to 11pm Klinika Bernardo caters to a clientele mainly from the MSM and transgender communities. We customized these hours for our clients based on what worked better for their schedules.”
Klinika Bernardo began in 2012 with four full-time staff and a small team of peer outreach educators. Demand for services was high. Almost 250 HIV tests and complementary pre- and post-test counselling services were conducted in the first two months. In 2013, 2034 tests were conducted, of which 169 were HIV positive. In 2014, from January to September, out of 1835 tests there were 145 HIV positive results, with 73 people being prescribed antiretroviral (ARV) treatment. In August 2014, of the 249 MSM tested at the clinic, 30 were diagnosed with HIV.
“We are clearly seeing a rapid rise of the epidemic among MSM and the transgender population,” noted Dr Ruiz, “especially among younger gay men, who currently make up almost 90% of the new HIV infections in metro Manila. We are seeing patients at all levels of society, from the upper socioeconomic level to the poorest of the poor. This is a crisis situation, I’m not exaggerating.”
Klinika Bernardo works with the Research Institute of Tropical Medicine's (RITM) Satellite Clinic in Malate, Manila, which is recognized as a centre of excellence for HIV services. Both clinics embrace a continuum of care service delivery model, while the RITM clinic can provide immediate testing and same-day results. Klinika Bernardo does HIV testing monthly, and it can take up to a month to get the results. This poses a challenge in ensuring that clients return for their results and, if positive, that they receive ARV treatment.
“Only about 36% of our clients return for test results. This really impacts our ability to reach an optimal number of people, and to ensure a significant data pool to help inform health planning policy and strategy,” said Dr Ruiz.
Recently, a new CD4 machine has strengthened the clinic’s service delivery model, and psychosocial counselling is also offered along with various health insurance schemes.
Meanwhile, the challenge of identifying and retaining HIV individuals across the continuum of care is being addressed by Klinika Bernardo’s ever-expanding team of peer outreach educators who operate at Quezon City area hotspots. One senior peer outreach educator supervises about 13 peer educators, each of whom is expected to reach 34 people a month, at least 10 of whom must be referred for testing – in other words, at least one-third of contacts are tested, about double the national average for outreach programs. The educators submit their reports monthly. The clinic currently has about 90 educators, and there are bimonthly training sessions.
“The majority of our outreach staff have professional experience already, and are college-educated,” said Dr Ruiz. “They link clients to rapid testing and STI services... sexually transmitted infections besides HIV are also rising in Quezon City and across metro Manila, including syphilis and gonorrhoea which are often gateways to HIV infection.”
Access to condoms and lubricants for MSM and other key populations continues to be an issue. “There’s a lot of stigma towards our community members when they want to buy condoms at pharmacies or other outlets,” said Mark, a senior nurse at Klinik Bernardo. “Our peer educators are given condom training so they in turn can instruct clients on how best to use condoms, and we also let our contacts know that they can get free condoms and lube at our clinic. Condom use remains very low between regular partners even though people are generally aware of the importance of using condoms at all times.”
The peer educators are skilled at taking a contact’s history: “We look at the person’s life as a whole, to the extent that we can, and we provide referrals, counselling and motivational guidance,” said Mark. “Quite a few of us are trained in stigma reduction techniques as well, so we can identify self-stigma within an individual which may have contributed to risky behavior, there’s a definite link there. We also work with church groups and religious leaders, police and government officials to make them understand how important it is to accept and reach out to our communities from a public health point of view. The Quezon City mayor’s office has actually facilitated our service delivery network.”
Klinika Bernardo also plans to work with local media to ensure better reporting on HIV and other issues impacting the communities, through the USAID-funded Project ROMP (Reaching Out to Most at-risk Populations). The clinic is also going to take part in efforts to better map the communities, to help with community population size estimations, including for MSM and transgender people, people who inject drugs, and children and young people living with HIV.
“Surveillance and mapping are key tools in our effort to better serve our communities,” said Dr Ruiz. “We report our data to the National Epidemiology Center. But…behind every statistic there is a real person, and it’s our personalized, confidential and respectful service and support that is our cornerstone.”
KB14EPN knows this full well. “Klinika Bernardo has given me confidence,” he says, taking off his surgical mask and revealing his face. “I need to be alive, this is not the end. I will not let the virus spoil my life. I want to be well. And I want to help others like me, here at Klinika Bernardo.”