Fighting the HIV monster

MANILA, Philippines - He chose the name Tarabusaw for his yahoo.com address, after a monster in human form that eats humans, perhaps to prepare himself for the task ahead: curbing the alarming increase in the number of Filipinos newly infected with the human immunodeficiency virus (HIV).

“The HIV problem is really out of control. Filipinos are getting infected at the rate of two new cases a day, and that is just the ones we know about,” Dr. Edsel Salvana tells STARweek.

Data from the Department of Health’s National Epidemiology Center (NEC) show that 210 new cases were reported for the year 2005, totaling 3,800 HIV cases reported since 1984.

In October 2009, the NEC reported 629 new cases, and perhaps 24,000 yet unreported HIV cases.

According to the NEC, it took the Philippines 10 years to double the number of new HIV cases before 2007. “But in the past year, it took only two years to double our cases. So if the doubling happens every two years, there could be 20,000 new cases per year by 2020,” he adds.

Salvana, who returned in July 2007 through the Department of Science and Technology’s Balik Scientist program, says he felt he had to help after realizing he was the only one among the doctors in the Philippine General Hospital’s infectious disease section with extensive training in treating HIV and the resulting acquired immunodeficiency syndrome (AIDS).

“In one month, I saw 12 new HIV/AIDS cases. The youngest was 21 years old. He had symptoms which (occur only in) very advanced HIV cases, which means he got this when he was much younger. And I felt this is just ridiculous, we have to do something,” he says.

Salvana says life can still be good for a person infected with HIV. For up to 10 years, a person can be HIV-positive but without full-blown AIDS. How long an HIV-positive person staves off AIDS is “a testament to how good your body’s immune system is. When we start you on the medications promptly, you will have a chance of recovering some of your immune function. There is no cure for HIV right now, but there is effective treatment,” he says.

 Salvana says he was always interested in science, though he admired doctors, particularly his pediatrician, Dr. Demetrio Africa. When he was about to graduate from the Philippine Science High School, he applied for and was accepted in the accelerated course in medicine offered by the University of the Philippines.

“At that point, I wasn’t ready to jump into medicine yet because I still wanted to be a scientist. Instead of going into Intarmed, because the curriculum scared me – 23.5 units for one semester – I elected to go to BS Biology,” he says.

By the time he was in his fourth year in college, Salvana was doing biomedical research, looking at “amobae, parasites that would infect the brain… really fascinating stuff.” Research into these microbes and then UP chancellor Dr. Ernesto Domingo inspired Salvana to go into medicine.

Salvana says Domingo, whose daughter he later married, “is a very distinguished doctor but at the same time he was also a basic scientist. He is now a national scientist.”

Even in medical school, Salvana never stopped doing research, particularly on tropical medicine. “I like parasites, worms,” he says.

After earning his degree in 2001 from UP Manila, he took up a residency in internal medicine at the Medical College of Wisconsin in Milwaukee. He then went on to earn a diploma in tropical medicine and a fellowship in infectious diseases, both at the University Hospital’s Case Medical Center in Cleveland.

“I also learned a lot about resistant bacteria, superbugs, flesh-eating bacteria, those things that kill people. It’s a well-rounded education, except I chose to focus on tropical diseases,” he says.

When his training ended, he decided to come home.

“I was interested in tropical medicine, so where are the worms? They’re not in Cleveland. They’re in the Philippines, so I said maybe going home is a pretty good idea,” Salvana says.

Through the Balik Scientist program, he received his appointment at the National Institutes of Health, at the Institute of Molecular Biology and Biotechnology. “The thrust is to look at low-cost, high-tech diagnostics for the Philippines, translate what they have in the US and form our own homegrown diagnostics for dengue, H1N1, and make them affordable. That was an interesting institute for me to join. There’s a lot of basic science involved,” he says.

At the same time, he received a cross-appointment at the PGH’s infectious diseases section. “That was it. I was all set to do my research, doing my practice to support myself, teach fellow residents,” Salvana says.

 In the course of doing research and seeing patients, he realized that there were two diseases in the Philippines that doctors were neglecting. “They are potentially becoming huge problems in the Philippines,” he says, noting that these diseases are HIV and methicillin-resistant staphylococcus aureus (MRSA), also known as the “superbug.”

MRSA is “a resistant form of the bacteria staph aureaus, which can kill even young, healthy people, and which actually emerged a lot in the US while I was training there. It hasn’t yet emerged in the Philippines, but over the course of 2008, we were seeing a lot more MRSA, and we were also seeing a doubling of the number of HIV cases,” Salvana says.

He put his interest in tropical diseases – he calls them his “first love” – on the backburner to focus on HIV and MRSA. He has applied for research grants to study the characteristics of MRSA in the country and is waiting for the results.

He says knowing MRSA in the country better is important “in terms of preparation when the epidemic hits, because it has happened in the US. We had young people actually dying of severe pneumonia or basically very bad skin lesions.”

He said a lot of the patients who die from MRSA were found to be “colonized” by the superbugs. “This can be found in your nostrils, armpits, it lives on your skin and doesn’t do much until maybe your resistance is a little low or it gains entry into your bloodstream. It is a scary thing. MRSA is one of the priority diseases of a lot of international disease societies,” he says.

Salvana says MRSA is “becoming a problem” at PGH, but not yet in the rest of the country.

“Usually PGH is a little ahead because we use a lot of antibiotics and we see a lot of cases, they’re all concentrated there,” he adds.

 Though Salvana is concerned with the spread of MRSA, the bigger advocacy he is pushing is HIV awareness, prevention and treatment, as well as trying to remove the stigma associated with it.

He says HIV is a very difficult disease to manage because “it’s very complex,” with the antiretroviral drugs having a lot of side effects and reactions with other medicine, as well as being very expensive, costing $200 to $300 a month per person. The regimen in the US is one pill once a day, but costs around $1,600 to $1,700 a month per person, “not counting other medications for prophylaxis, or if they get into the hospital.”

Part of his campaign is being active in the PGH’s AIDS clinic, which tests people for HIV for only P180, “but if you really don’t have money, we can think of a way,” Salvana says.

Salvana also organized a rock concert last Sept. 5, 2009, after the Australian Red Party, which stages similar events, asked him to hold a parallel event so the PGH could get its own AIDS clinic equipment. The CD4 machine, which costs P3.5 million, will arrive sometime this year, he says.

“The reason the CD4 cell is so important is because it’s like the coordinator for the body’s immune system, and if that gets hit, your immune system is really shot,” he says. “You do need to keep track of your CD4 count. In the US, we check it every three to four months. In the Philippines, you’d be lucky to get it twice a year.”

Aside from the funds raised, the concert made people aware there was a problem and that they had to deal with it.

“We’ve been lucky so far. Compared to the big picture, with people dying of other diseases, (the incidence is) low. But what we have now is the opportunity to intervene while our case numbers are still going up. This is like San Francisco in the 1980s. If they knew what we know now, they could have stopped that thing in its tracks,” Salvana says.

What he wants to happen is for the law to be changed. Salvana says part of the problem with tracking the spread of the disease is local laws require a person to “opt in” or give informed consent before he can be tested for HIV.

“This was a good idea in the 1980s, when we didn’t have good treatment for HIV. What we really wanted to prevent was discrimination. But now that we have treatment, we should treat it more like another chronic illness, like diabetes, asthma, high blood pressure, because that’s what it is,” he says.

To put things in perspective, Salvana says the HIV virus, outside the body, is a “fragile virus. Expose it to air for two minutes, and it dies. Expose it to even just water, and it dies.”

The most cost-effective way to curb the spread of HIV is prevention. With the availability of drugs, “it would be a shame if we turn into post-San Francisco in this day and age. We know what happened in Africa, where there are only very old or very young people. That is what HIV can do to a population. It strikes at the most productive members of society. That has far-reaching implications, even from just a societal standpoint.”