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Darwin Tenoria first learned about HIV when he was on his deathbed. He was 27 and weighed just 70 pounds.

“I died for two minutes and I was revived in the hospital,” he remembers. When he woke up, he says, “my doctor asked me: ‘Did you undergo HIV testing before?’ I said: ‘What’s HIV? What’s that?'”

His test came back positive. Tenoria began treatment. When his health stabilized, he was determined to do something. He quit his office job and became an HIV educator. Now, 10 years after his near-death moment, he is stunned by what is happening in his native Philippines.

Darwin Tenoria first heard about HIV when he was in the hospital critically ill from the virus. Whe he recovered, he became an educator to make sure people are given critical information about sexual health.

Gabrielle Emanuel/NPR

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Gabrielle Emanuel/NPR

The disease is spiking dramatically.

“We used to call [the HIV epidemic in the Philippines] hidden and growing, but now they are saying it’s fast and furious,” says Dr. Loyd Norella, who manages the HIV program at the Pilipinas Shell Foundation — the foundation arm of the energy and petroleum company Shell Philippines, part of Shell Global.

And Tenoria has an answer to the question of why. When he visits schools to talk to students about HIV prevention, it’s not uncommon for the administrators to say to him: “Please don’t discuss condoms.”

He believes the Philippines has the tools and knowledge to combat HIV – and yet stigma around sex and HIV means new infections have soared from 4,400 in 2010 to 24,400 in 2022 and yearly AIDS-related deaths have shot up more than 500% over the same period to 1,500.

What’s happening in the Philippines is part of a seismic shift in the global HIV/AIDS landscape.

Sub-Saharan Africa has long been the epicenter of the HIV crisis. But in recent years, new infections and AIDS-related deaths have plummeted. Meanwhile, dramatic spikes are happening in other regions, from South Asia to Eastern Europe to Latin America.

“We have victory in sight, and yet complacency could lead us to seize defeat from the jaws of victory. That would be a human tragedy, but it would also be economic bonkers [given what’s been invested],” says Peter Sands, executive director of The Global Fund.

Experts are studying the new landscape to learn what has worked well — and what innovative strategies might be useful in the new hot spots. In one example, health officials in the Philippines have set up a testing clinic deep inside a cavernous mall parking garage for people who might shy away from entering an on-the-street HIV facility.

What’s behind the new HIV map

Today, Africa still has the highest number of people living with HIV — roughly 26 million. But there’s been major progress in slowing down the virus, say public health experts. New infections and AIDS-related deaths are down nearly 60% in sub-Saharan Africa from 2010 to 2023.

An estimated 1.3 million people were newly infected with HIV in 2023, but for the first time in the history of the pandemic, the majority of those new cases — 655,000 — were outside of sub-Saharan Africa.

Mary Mahy, director for Data for Impact at UNAIDS, calls it “incredible progress.”

But this good news stands in stark contrast to what is happening elsewhere in the world, she says. If you remove sub-Saharan Africa from the world’s HIV data, then all the progress on curbing new infections disappears. “And that’s a really sad situation.”

In at least 28 countries — from Venezuela to Egypt — new infections are ticking up. While the likelihood someone in Africa will get HIV during their lifetime has dropped from a whopping 21.8% in 1995 to 8.7%, the chances for someone in Central Europe, Eastern Europe and Central Asia to contract the virus have increased from 0.4% to 2.8%, according to Austin Carter of the Institute for Health Metrics and Evaluation at the University of Washington. His findings were published this month in The Lancet HIV.

The progress in sub-Saharan Africa is a testament to national and international efforts. The U.S. deserves a lot of credit, putting more than $110 billion toward the effort — the largest commitment by any nation to address a single disease — over the past two decades.

On the ground, a lot of the progress has to do with the development and rollout of life-saving treatments that help the HIV-positive person live and can prevent the virus from spreading.

But, experts warn, nothing can be taken for granted with HIV. Today, some 30 million people are on treatment — more than ever before — but they need to stay on treatments the rest of their lives. “HIV is a formidable adversary. It comes back and it comes back fast, if you don’t pay attention to it,” says Sands of The Global Fund.

“Frankly, we’re getting to a situation where it is not the money and it is not the technology that is stopping us from beating AIDS,” he says. “It’s stigma, discrimination and bad policy. And if we can’t fix that, all the best innovations in the world won’t work. So it is really quite a crossroads.”

An AIDS activist sees that exact dilemma in the Philippines: “All the interventions are here. We have free HIV testing. We have free condoms and lubricants. We have free PrEP [to prevent HIV infections]. Then there’s free antiretroviral medicines [if you are infected]. And yet, the cases are rising. Deaths are rising. So what’s wrong?” says Ico Johnson, who founded Project Red Ribbon, an HIV advocacy and care nonprofit in the Philippines.

In the Philippines: ‘I didn’t want that to happen to other people’

As a child, Tenoria — the HIV educator — says he knew he was gay. But he also knew that, back then, being openly gay came with a lot of stigma. Talking about sex was rare — if not unheard of — in this heavily Catholic country, he says.

Given his own HIV crisis, he hopes to make sure everyone has the sexual health information he didn’t. “I don’t want that to happen to other people,” he says.

His work as an HIV educator, counselor and advocate has taken many forms — he currently works at the Pilipinas Shell Foundation focusing on HIV treatment. But one aspect of the epidemic has always been of particular importance to him: Infections in youth.

Almost half of new HIV infections in the Philippines are in people under age 24. So many of those at highest risk are too young to remember the days when HIV wrecked communities.

Mahy, of UNAIDS, says this is a problem far beyond the Philippines. “That threat and the reality of your friends dying or family dying is not there,” she says. Even young people who do know about HIV are less afraid of it and less likely to take precautions, she says.

Outreach to such a young population is a challenge. “These kids are not in the streets. They are at home. They are in school. There are government and community-based organizations that have testing and prevention centers, but you don’t expect these kids to go there,” says Dr. Rossana Ditangco, the HIV research program lead of the Department of Health’s Research Institute for Tropical Medicine.

Norella, of the Pilipinas Shell Foundation, has zeroed in on a particularly risky window. A behavioral survey from the Department of Health found that men who have sex with men and transgender women start having sex, on average, a year before they start using condoms. “So that probably explains why we have a lot of transmission in our young populations,” he says.

While the Philippines recently reduced the age of testing for HIV without parental consent from 18 to 15, there’s still a law prohibiting children under 18 from purchasing or even being given free contraceptives including condoms, which can prevent transmission of HIV. As a result, Norella says, many adolescents must get condoms informally through a relative or older friend.

When school administrators stop Tenoria from discussing condoms as the cheapest way to avoid HIV, he says, it’s “difficult” and “frustrating.” Part of it is religion, he says, and part of it is bucking long-held social norms.

The result of making certain topics taboo, he says, is a tremendous information gap. In a national survey of those most at risk of HIV, just about a third of men who have sex with men and transgender women could answer five basic questions about how HIV is transmitted, such as whether you can get it from a mosquito bite and whether a healthy-looking person can have HIV.

Tenoria says sometimes it feels like he’s pushing against a closed door. But health officials and activists are trying new ways to push that door open.

A solution in a garage

In Quezon City — part of metro Manila — the health department realized that many people didn’t want to go to pop-up clinics and mobile vans for HIV testing lest they be seen by others.

“Some of our clients wanted a discreet place,” says Wilson Atilano, who works with Quezon City’s health department and is funded by The Global Fund.

He says city officials searched for a discreet location. They found it deep inside a shopping-mall parking garage – now home to the country’s first park-and-test HIV clinic. Since the garage serves shopping malls, there’s a convenient excuse for someone who needs a cover story.

“So they can park over here or over here. And we can do the testing,” Atilano says, pointing to the concrete parking spots with classic yellow lines dividing them.

Wilson Atilano works with the Department of Health in Manila to make HIV testing and care more accessible. Above: He’s standing in a mall’s underground parking garage, where a park-and-test clinic opened this summer.

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Clients can stay in their car the whole time and get test results within 20 minutes, he says. “If there is a negative, they can exit,” he says. If they are positive, they can get counseling, treatments, refills – all in the privacy of the parking garage.

The garage clinic is also surrounded by call centers, where, says Atilano, “a lot of the employees are LGBT.” He says many of the call centers, which serve U.S. companies, are known for being particularly willing to hire LGBT employees.

Reaching this population matters because nearly 90% of those newly infected with HIV in the Philippines are men who have sex with men.

While acceptance of the LGBT community has improved significantly in recent years, local AIDS activist Johnson doesn’t want gay men to be the image of HIV/AIDS.

Instead, he wants to take a page from Africa’s successful playbook.

In sub-Saharan Africa the majority of new HIV infections are in the general population — not in marginalized groups. There, it’s a universal problem. While, outside of sub-Saharan Africa, 80% of new infections are in marginalized groups, such as people who sell sex, people who inject drugs, LGBT individuals and prisoners, according to UNAIDS.

“When those populations are stigmatized or are criminalized or marginalized in some way and they can’t access prevention or treatment services, those new infections just keep continuing along and along and don’t ever decline,” says Mahy.

Johnson wants to change the mindset that only LGBT folks are vulnerable. His nonprofit, Project Red Ribbon, has a particular focus on medical care and advocacy for HIV-positive kids, who typically get the virus from their mothers.

An HIV-positive child gets his blood drawn at Project Red Ribbon, an HIV care and advocacy nonprofit in the Philippines.

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“That changes the perspective,” says Johnson. The message he hopes to send: “Your kid can be affected. Anybody can be affected.”