Beyond the “public health paradox”: Explaining rising HIV infections among youth in the Philippines

To the Editor: Alibudbud1 calls attention to rising HIV infections among young people in the Philippines and increasing access to preexposure prophylaxis (PrEP), an effective, preventative medication. The Philippines has the fastest-growing HIV epidemic in the Asia-Pacific, and about one-third of newly diagnosed cases in early 2025 were among people ages 15-24 years2,3, highlighting the article’s importance. However, the “public health paradox” in the title may be interpreted causally rather than rhetorically, even though the author does not claim that PrEP is causing the rise in HIV infections, or that PrEP has failed. The absence of a clear definition of this phrase in the main text risks ambiguity. If readers misread the article as suggesting PrEP failure, confidence in its use may be undermined. It may also draw attention away from the structural and implementation-related factors which offer more direct explanations for the rising HIV infections. At first glance, I interpreted the article’s headline as suggesting risk compensation, the idea that people may take more risks when they feel protected (e.g., reduced condom use, more sexual partners), leading to increasing HIV infections. Yet, there is mixed evidence for this among PrEP users, and it is unlikely to explain population-level HIV trends in the Philippines because PrEP coverage is too low. The author mentioned that the number of people actively receiving PrEP each year has increased from 4 263 in 2021 to 15719 in 2023 (actually it is now roughly 30000 estimated cumulative PrEP initiations4). Coverage remains far below the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended thresholds for population level impact, making it epidemiologically implausible for current PrEP scale-up to have influenced population level HIV incidence trends. The article1 notes crucial factors contributing to the epidemic, such as stigma, which discourages use of testing and preventive services, and the downsizing of sexual health services because of the United States Agency for International Development (USAID) funding constraints. Structural issues are acknowledged in the article but not developed as the main explanations. There could have been discussion about inadequate HIV prevention funding3; limited PrEP coverage and health system capacity constraints; high-risk sexual behavior; inadequate sexual health education; gaps in the HIV treatment cascade; and geographical and economic inequities in access to PrEP and other services. Alibudbud1 argues for increased funding, youth-focused HIV education, expansion of telemedicine, decentralization (e.g., pharmacies dispensing PrEP), and better monitoring and research and family involvement. These suggestions do not clearly link back to a “public health paradox”. I would like to add the following: a need to expand and normalize HIV testing and prevention services including innovative options (e.g., long acting injectable PrEP), which should be affordable and accessible. Sexual health curricula in schools (addressing contraception, HIV transmission, and PrEP), campaigns combatting stigma and discrimination around HIV and lesbian, gay, bisexual, transgender and queer (LGBTQ) people, and the involvement of youth in planning and implementing HIV responses5, are urgently needed. In conclusion, if any paradox exists, it lies not in PrEP—which is highly effective when used as directed—but in the rhetorical framing of public health issues. Conflict of interest statement The author declares that there are no conflicts of interest. Funding The author received no extramural funding for the study. Publisher’s note The Publisher of the Journal remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Edited by Zhang Q, Lei Y, Pan Y