We have chosen to present the data in a case-series format, referring to a type of medical research study that tracks subjects with a known exposure, such as patients who have received a similar treatment, or examines their medical records for exposure and outcome. Looking at individual cases rather than across-the-board themes has the additional benefit of showing the complexity of each of the participants' lives, where much of the explanatory power of the study is located. The cases of the eight most salient of the 12 participants are presented in this paper; the remaining four participants' stories corroborated many of the themes that arose in the other narratives. The men were on average 25.8 years old (range: 19 to 42 years). Three worked in mid-to senior office/corporate jobs; three worked in lower-office jobs; three were teachers or trainers; two were students and one (the oldest participant) was an unemployed manager. Half were born in the Metro Manila area and the others had migrated to Manila at a later age. Three of the men presented in this paper had still never tested for HIV despite considerable risk for HIV infection; the others had, by the time of the interview, been diagnosed but were selected because they had postponed HIV testing for 2 or more years after possible exposure.
The first case, Joey, was 33 and lived in Quezon City. Since having tested once, some five years ago, he declined to go for a new HIV test in the years that followed, despite describing himself as a "serial monogamist" who never had a relationship that lasted longer than a number of weeks, and who did not use condoms consistently. He referred to himself as "very high risk" and commented that "I may very well be positive at this time." Joey knew several people who worked in the HIV field. He commented:
It's not that I never wanted to take the test, it's just I never got around to taking the test. [Chuckles] [...] I guess there's that part of me that just totally ignores the importance of testing. I mean I hardly see you or anyone of our friends in the HIV advocacy, things get really busy at work and when I'm not at work, I play.
Joey mentioned that he had "12 or 13 friends with HIV apart from those who died over the past years." This also had not led him to feel the need to get tested: "No. Stubborn, right? I guess I'm apathetic when it comes to death or maybe I am just good in ignoring things I would prefer to ignore. I don't know".
Nicolas, age 42, from Pasay City, currently unemployed, was diagnosed with extra-pulmonary tuberculosis (TB). He said his healthcare provider never told him that an HIV test is recommended for all TB patients. Nicholas said he used condoms infrequently and mentioned several instances of sexual risk-taking. Despite this, he said he never wanted to get tested since he said he was "physically okay"; he was a gym fanatic, which he said was a characteristic of the gay lifestyle. Outreach workers approached him for an HIV test several times over the past years, but he said there was no need because "I knew I was healthy." Later it became clear to Nicolas that he had several friends who were sick with AIDS. He continued to strongly associate having HIV with signs of physical deterioration typical of AIDS:
I had five friends. The first one had boils all over his body. The other one we visited in [Hospital], he was so thin and had suffered much weight loss. That's how I knew I was okay. I was healthy and I didn't have weight loss.
Nicolas met outreach workers regularly in a gay bar in Quezon City. Occasionally, there were mobile testing facilities there, but he still did not want to get tested: "[I]t's a bar, you know, people, when they see you lined up for an HIV test, they will judge you." He was also worried about confidentiality and seemed to be irritated by the persistence of HIV outreach workers inviting him for an HIV test: "In order to get rid of the outreach workers, I would take condoms and lube [from them], but I never got tested." He appeared to question the professionalism of the outreach workers he had met: "There's this back area at the bar where you can cruise and have sex in the dark. And the outreach workers will be in the dark as well [laughs]." Nicolas knew that oral sex, his preferred sexual behavior, was less risky than anal penetrative sex and he used this knowledge to justify his decision not to get tested:despite having engaged in unprotected anal sex occasionally. While he was younger he had gonorrhea twice, and found out about how to treat it; he bought medicines via the Internet. He never saw a doctor for his symptoms. Nicolas never looked for information on HIV via the Internet; again he explained it pointing to his physical health: "I did not have signs, symptoms or weight loss." Nicolas was not aware that STI and HIV treatment are available for free at the social hygiene clinics in Greater Manila.
The third case, Drake, age 33 from Quezon City, found out he was HIV positive in September 2015. In the 14 years prior, since he became sexually active at age 17 or 18, he had never sought an HIV test because he always used condoms and usually did not engage in anal sex. He believes he was infected when he used the drug Ice (methamphetamine hydrochloride or crystal Ice) for the first (and only) time, during which he had condomless sex. He mentioned that he felt something wrong about his health a few times since then: "[The] first reason is I could feel something that I couldn't explain, but I knew that there was something wrong. And second, my best friend had herself tested and I accompanied her." Drake said that he was worried about his confidentiality at the HIV testing center: "[Other clients waiting to be tested] will know if a person is positive or not based on [his] reaction when he comes out of the post counseling [room]." When Drake tested positive, he told his best friend right away, but she did not believe him: "She said I was such a good actor." Drake thinks his friend does not want to believe that he is positive; perhaps she would not know how to deal with it.
Case number four, Robert, who was 26 and from Manila City, wanted to be a woman and experimented with hormones while in high school, but then decided that life would be easier as a gay man. He became sexually active from when he was raped at the age of six or seven, and would subsequently never use condoms, as he said he preferred the feeling of being anally penetrated without them. Robert looked for information about HIV online but this did not result in him getting an HIV test. He did not want to be tested because he was worried he would be the only one who was positive in his group of friends; for that reason he preferred, for a long time, not to know. In July 2015 he underwent his first-ever HIV test after being convinced to test by his (gay) boss, who was suspicious about a cough that Robert had and which refused to go away. Robert tested positive for HIV. He said he felt sorry that he had not tested earlier, and seemed to blame himself for it: "I was self-centered before but I didn't know that being positive can reverse your life, either for good or bad. [...] And because I was that self-centered, I always went for whatever made me happy." Once Robert found out, he decided to tell his siblings, but not his parents "because they are already senile." However his sister then told his mother that he had "AIDS": "My mother texted me to go to church, pray a lot, go to Cavite where there is a healing priest there. I told her not to worry." Robert disclosed his status to his friends and colleagues too, including his staff and his boss, who was an important inspiration for Robert to get tested. Robert had a very positive framework for dealing with HIV:
I didn't take it as punishment, but I took it as a new challenge. There is nothing new in my life aside from office, work, and partying. But when the virus struck me, I saw this as a reason and as a challenge to live longer.
The fifth case study, Justin, aged 28 from Quezon City, found out he was HIV positive in March 2015 with a CD4 count of just six. He had been in a presumably monogamous relationship with his first boyfriend for a period of 11 years. Initially they used condoms, but in the past two years, according to Justin, they had stopped using them. He had had several symptoms of AIDS-related disease in the months before finally taking the test, including TB of the lymph nodes, and had been in contact with medical authorities to test for many different diseases, including TB, cardiovascular disease and cancer:
I felt there definitely was something wrong. [...] That's the time I started to search online for common symptoms. [...] My EENT told me to have my lymph tested to know if it was cancerous [...]. That night I posted on my Facebook that I might die tonight. People were aware that all my lab tests were negative. Some friends were even texting me but never directly told me to get tested for HIV, but eventually one of them told me to do so. A very close friend of mine [...] told me, "Son, I love you but son of a bitch, get HIV tested as I don't want you to join the [death] statistics."
Justin seemed totally convinced that it could not be HIV because of his monogamous relationship with his boyfriend, but also because of his boyfriend's and his own family's status as doctors, which led him to classify himself and his boyfriend as "low-risk":
I was already aware of [the HIV service NGO] and my friends in Malate, like X and Y they were always telling me to be careful, but since they know that my partner and I came from a family of doctors, they were sure that we are safe. Also in my ex's family, being a family of doctors, HIV was a common discussion or topic.
Justin also thought that the healthy looks of his partner meant he could not have HIV:
I am not that equipped with correct info and my partner seemed healthy based on his physical condition, and there is that trust that [my] partner is healthy, aside from the fact that he is a doctor I had no reason to have doubts.
When Justin finally was tested for HIV for the first time, it was so crowded at the testing center that he turned around and left, saying he felt "afraid and intimidated"; he came back later dressed in different clothes and wearing a cap, fearing to be recognized. When he finally tested positive (in March 2015), his boyfriend of 11 years admitted that he had known that he was HIV positive for the past 5 years. Despite this, Justin was willing to stick with him, but his boyfriend insisted on a break-up:
Even when we were in our [HIV] training [2 weeks before the interview, ADC], I was crying and I was saying I felt bad, not because I acquired [HIV] but I felt bad because after I acquired it from [my boyfriend], he left me.
He saw himself as a "victim of love," but said his HIV infection was partly his own fault too:
But lately I realized, and it's funny, I think back, now that I'm taking ARV-I have seen that same bottle before, with my ex! But admittedly that was one of my mistakes, I never asked him anything that connected him to being positive, I didn't even search online what are those bottles and pills I had seen [him take]. All he said was that medical representatives gave him those pills for trials.
Justin received the test result in the company of a family member, and told his entire family about his HIV status the same day. They responded well:
When I finally blurted out the news, there was that moment of silence and they were all just staring at me. My brother told my parents, "Why, dad? Can't you give your favorite child a hug? Ma, can't you hug him? He's your favorite, can't you stand up and go over his side and give him a hug?" Then they stood up and gave me a hug and uttered, "We shall fight!" The day after, my Mom accompanied me to [the hospital].
Justin also disclosed his testing HIV positive to colleagues at the place he was teaching and was well-supported; colleagues collected 10,000 pesos to help with his medical expenses and over the following months his weight went up from 42 to 56 kilograms: "The support I needed came and I never had to look for it." Asked why this might be the case, he responded:
I guess it's because I have been a good person, that's why I have been getting all the support, care and love that I need from them. They were all surprised to know, but they all managed to understand my status and looked at the things I am capable of rather than dwelling on the idea that I am sick and I am limited. My family has been very supportive ever since, and I don't see a reason for them not to accept me [smiles]. My friends and officemates normally entrust their secrets and stories with me, I kept them, didn't judge them, I guess that's why am getting the same respect and acceptance I have given them.
Note how Justin, by positioning himself as "good" and, indirectly, as an innocent victim of HIV, managed to obtain strong support from family, colleagues and friends. He could navigate the tremendous societal stigma of having HIV, and of being gay, by positioning himself as morally upright. Justin 'read' his social environment well, and marshaled societal and family support to keep going in the face of the social and institutional stigma and discrimination that characterizes life for many Filipino MSM living with HIV.
Case number six, Vince, aged 26, from Manila, has been involved in male sex work for short periods of time to make ends meet since he was 22. He was employed as an administrative assistant at the time of the interview. He had not tested since 2014, despite having been at considerable risk for HIV. He said he was not "effective" when using condoms with his partners, meaning that he would lose his erection. One of his ex-boyfriends tested positive recently, and a steady sex partner of Vince whom he described as a client also recently tested positive for HIV; with both his ex-boyfriend and this steady client Vince would not use protection. Vince gave the distance to the testing clinic as a reason not to get tested, and also his work schedule, which he described as "toxic." He mentioned the long waiting times as a factor that might put people off. He seemed resigned to the fact that he might have HIV: "I guess I've long waited for and expected a positive test result". He had not made plans to get tested at the time of the interview, despite the interviewer's advice to do so.
Case number seven, Zen, aged 21 from Pasay, grew up in Manila and started working as a fast-food crewmember recently. He became sexually active since the age of 18 and would generally not use condoms. He found sex partners via online gay dating apps and the online messaging services Planet Romeo and WeChat. Commenting on what made him decide whether to use condoms or not, he said: "It depends on the looks of the person, if he looks healthy or when I have been exchanging texts with the person for some time, I would trust him and condoms would not play a role anymore." When Zen had a persistent sore in his mouth, a former boss who was a nurse told him he should have it checked out and also be tested for HIV. After this he found out he was positive in November 2014. He said two factors explained why he had not taken an HIV test earlier, which were similar to Vince and Nicolas above: he had been "busy" and "the fact that I wasn't feeling anything bad or odd about myself." This suggests that for Zen it remained difficult to conceptualize or internalize the idea of a communicable disease without symptoms. The Filipino context of pervasive stigma and discrimination against homosexuality and HIV must also have played a role in maintaining Zen's denial of his potential HIV infection for several years. Zen has not told anybody about his HIV status except the people he has met via his access of HIV services. He believes his brother, to whom he is close, would understand, but he feels embarrassed and he seemed to judge himself in a moral sense: "[I got HIV] because I didn't think and took for granted my health and the risks that come with the action".