The Philippines largely dodged the AIDS crisis. That's changing.

Cebu City has been listed as one of the areas of the Philippines with the highest increase in HIV cases. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

Increasing HIV infection rates are raising fears that the Philippines will be faced with a public health crisis that it has long escaped.

Since the Philippines reported its first case of HIV in 1984, the island nation has had one of the lowest rates of infection in the world; less than 1% of its 100 million population has been infected with the virus that causes AIDS.

But that may be changing.

Globally, new HIV infections have fallen dramatically in recent years, according to UNAIDS, the United Nations’ program to combat the disease. But in the Philippines, more than 20,000 new HIV infections were reported from 2010 to 2015 — more than four times as many as had been recorded in the 26 years before that.

Performers get ready for the annual World AIDS Day parade in Manila on Dec. 1, 2015. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

Along with India and Pakistan, the Philippines is seeing new infections and AIDS-related deaths sharply rise among men who have sex with men and among transgender women, sex workers and people who inject drugs.

A nationwide study conducted by the Department of Health showed that in some areas, infection rates among these groups were higher than 5%.

"That 5% threshold is like a tipping point," said Dr. Genesis Samonte, head of the department's HIV/AIDS monitoring and tracking unit. "There is already a large base of people who have the virus, so the rate of infection will be exponentially faster."

A woman in Cebu City, Philippines, lights a candle for her former partner, who comitted suicide due to depression. He was an intravenous drug user and tested positive for HIV. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

"No one is saying 'national emergency' yet, but a lot of people are thinking it," said HIV activist Tony Benfield.

Benfield, 53, vividly remembers the early days of AIDS, in the 1980s, when HIV had yet to be discovered as its cause and men were dying from what was called "gay cancer."

"I lost many friends then. It offends and angers me that I continue to lose friends today," Benfield said. "Back then, we called it for what it was. 'He died of AIDS,' we would say."

Rina and Gabby Cardinas, who have both been HIV positive for more than 10 years, live in a small town outside Cebu City, Philippines. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

But 30 years and many medical advancements later, HIV-related deaths are shrouded by attributing them to more socially acceptable diseases such as "hard-core pneumonia" or "brain tumor."

In 2009, Benfield was working for a nongovernmental organization when he began offering free HIV screening and counseling to friends through home test kits. Covering the cost of the $2 test kit himself, he would go out in his spare time to parking lots of malls or coffee shops to meet people — anywhere but the homes, offices or schools where they could be recognized.

It was basic but utilitarian. And it was better than the other options available at the time: government-run testing centers where clients could wait most of a day to receive their test, or private hospitals that charged as much as $100.

Benfield's testing service spread, initially through word of mouth, later through social media. But as it grew, so did the problem.

"Before, one out of five tested positive," Benfield said. "Now, it's more like four out of five. It's depressing."

An intravenous drug user uses a vacant room as his shooting gallery in Cebu City, Philippines. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

In 2012, Benfield and some friends opened Sustained Health Initiatives in the Philippines, a small private HIV testing clinic. Benfield considered it a memorial of sorts to a friend he had lost to HIV-related complications. He did not know the friend was HIV-positive until after he had died.

"It's a train wreck coming. Can't anybody else see that?" Benfield said.

The government did see it — as far back as 2009, when new HIV infections showed their first jump. Health officials noted that the virus, formerly transmitted primarily by female sex workers, now was being spread largely by men having sex with men.

Members of a community who identify themselves as men who have sex with men hide in the shadows in Cebu City, Philippines. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

The increase hit some areas especially hard. Cebu City in the central Philippines saw one of the biggest explosions in infection rates.

More than 70% of the total HIV infections are now attributed to men having unprotected sex with other men. Most of them are in the 25-34 age group.

The entrance to one of the lodges where commercial sex workers take their customers in downtown Cebu City, Philippines. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

The Health Department puts AIDS-related deaths since 1984 at 1,501. But health experts and activists alike say the number is grossly understated, with many deaths quietly passed off as pneumonia or meningitis.

From January to November 2015, there were 415 HIV-related deaths.

"That's more than one death every day — of mostly young gay men. Ignoring this is like saying that the deaths of gay men don't matter," said Jonas Bagas, former executive director of the Library Foundation, one of the first HIV awareness and advocacy groups in the Philippines.

The Health Department forecasts total HIV infections will reach 133,000 by 2022 if the current trend continues.

"To reverse the increase in infections, we need to increase condom use and bring it up to the level of 80%. We need to get people tested and get them on treatment," said Samonte.

Brother Paul Bongcaras from the Society of the Divine Word distributes condoms to sex workers in Cebu City, Philippines. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

Increasing condom use among men who have sex with men from its current level of 44% will mean overcoming social, religious and legal obstacles. Condoms are only sold in convenience stores and drug stores — mostly behind the counter.

In the heavily Roman Catholic country, condom ads and public service campaigns on HIV/AIDS are muted by protests from religious groups, which see them as promoting promiscuity.

And existing laws bar minors from getting an HIV test or being offered condoms from public health clinics without parental consent.

"It no longer responds to the current HIV situation," said Rom Dongeto, executive director of the Philippine Legislators' Committee on Population and Development. "Isn't it baffling that the government has no massive and sustained information campaign about HIV and AIDS, given this dramatic increase in new infections? This is a public health issue that is exploding as we speak."

A commercial sex worker puts on her makeup while waiting for customers in Cebu City, Philippines. (Veejay Villafranca / Pulitzer Center on Crisis Reporting)

The government is considering incorporating HIV education into public school curricula to catch risky behavior before it starts.

Bic Bic Chua, executive director of Catholics for Reproductive Health, decried a recent decision by Congress to eliminate the Health Department's contraceptive budget.

"We are running a race against time — against increasing maternal deaths, increasing teen pregnancies and increasing HIV rates. Nobody wins. We will all lose," said Chua.

Reporting for this story was supported by a grant from the Pulitzer Center on Crisis Reporting.