HIV/AIDS in Pakistan

HIV epidemic evolves in three phases. First phase is low prevalence, when prevalence of the disease is less than 5% in any high-risk group of the country. Second phase is concentrated epidemic when proportion of infected people in any high-risk group rises more than 5%. Third and last phase of epidemic is generalized epidemic when prevalence of HIV infection rises over 1% among blood donor or pregnant women. Like other Asian countries, Pakistan is following a comparable HIV epidemic trend having moved from 'low prevalence, high risk' to 'concentrated' epidemic in the early to mid-2000s. Pakistan's epidemic is primarily concentrated among two of the key population groups driving the epidemic in the country. These are people who inject drugs, with a national prevalence of 27.2% (weighted prevalence of 37.8%); followed by transgender sex workers, standing at 5.2% and then 1.6% among male sex workers. The prevalence in female sex workers still remains low at 0.6%. The geographic trend of key populations is from major urban cities and provincial capitals, expanding over time to smaller cities and peripheries.^[5]

Pakistan faced a low prevalence phase of epidemic from 1987 to 2003. This may have been due to lack of formal surveillance systems, although no study found significant HIV in any group until 2002. In 2003, an outbreak of HIV among injection drug users in one city heralded the onset of HIV epidemic in the country. Since then different studies and the national HIV surveillance (which started in 2004) have confirmed an escalating epidemic among IDUs and more recently among male and transgender sex workers. Currently the national average prevalence of HIV among IDUs is nearly 20%. Several cities also show concentrated epidemic among MSWs/ TSWs as well.^[6] However, as mentioned that HIV is taken as stigma in a culture such as that of Pakistan. This along with the absence of routine surveillance and testing for HIV in the health system, ascertaining the actual number will remain a challenge.^{[citation needed]}

Other groups that also have HIV among them are truck drivers, expatriated migrant workers and wives of IDUs. However, the incidence rate are not known for the reasons mentioned above. Two studies of men from the general population: Faisel and Cleland^[7] and A Study of Bridging Populations (The Population Council/ NACP 2007^[8]) show no HIV and few STIs in this group. Similarly a study of women attending labor and delivery clinics in four cities had shown no HIV and rare STIs (NACP 2001).^[9] Furthermore, blood donor screening data all over the country are suggesting low HIV infection in the blood donor population, albeit with some increasing trends in selected centers.^{[citation needed]}

A number of factors may have contributed to keeping the overall transmission of HIV within the general population. One, Pakistan is a predominantly Muslim country with near universal circumcision. Secondly, taboos on sex may have led to a higher proportion of the need for non-marital sex to be met via sex between men, much from a smaller group of men within each person's acquaintance. Some of this is suggested by the fact that about 45% of all sex acts sold are by either male or transgender sex workers (HIV/AIDS Surveillance Project 2007). These factors may have led to a high rate of HIV transmission among MSM/MSW networks but may (temporarily) slow down the transmission of HIV to the rest of the population.^{[citation needed]}

The low prevalence rate overall may be taken as a window of opportunity, still available and actions to curb any further disease spread should be roboust. However, it is worth mentioning that data is reported mainly from the public sector health facilities. While, the current health seeking behaviours and health system forces majority of the population to the private sector.

The table above shows the sample distribution of high risk group done by the NACP.^[10]

A major factor that must be accounted for in the overall HIV transmission scenario is the rampant use of therapeutic injections, often with non-sterile injection equipment. There are an estimated 800 million therapeutic injections given annually in Pakistan or approximately 4.5 per capita. This is among the highest in the World. A small but significant proportion of these are reused. This has led to the prevalence of Hepatitis C infection (which is nearly exclusively transmitted via blood exposures) to become >5% nationwide, although this seems to have stabilized at a national level. Conservatively this suggests around 150,000 new HCV infections annually, leading to the conclusion that HIV can also potentially spread via this route as well. Indeed, recent community based outbreaks in Punjab suggest that the process may have already started.^{[citation needed]}

Pakistan's response to HIV/AIDS began in 1987 with the establishment of a Federal Committee on AIDS by the Ministry of Health. The national AIDS control Program was then established. Its objectives are the prevention of HIV transmission among specific population sub-groups, safe blood transfusions, reduced STI transmission, establishment of surveillance, training of health staff, research and behavioral studies, and development of program management.^{[citation needed]}

The prevention efforts received a major boost since 2004 when a World Bank loan/grant allowed the Ministry of Health (and the provincial Departments of Health) to start a program which seeks to provide HIV prevention services to IDUs, sex workers and truckers; perform advocacy and communication for the general public and covers significant proportion of the national blood supply for HIV, HBV and HCV screening. This "Enhanced HIV/AIDS Control Program" has been able to establish these services using NGOs to perform the interventions in most large cities although the quality of the services as well as the completeness of their "coverage" remains low. Overall the IDU programs in Punjab are performing the best with over 70% coverage of target populations with services in 4 cities. Programs for sex workers lag somewhat but are bolstered by the fact that the metropolises have higher levels of knowledge and safer behaviors. However, the overall levels of coverage of services remain low at around 16% for IDUs and <10% for sex workers nationwide. The communication project has performed probably the least with only 44% of Pakistani women reporting ever hearing of the word "AIDS" in 2007.^[11] Finally HIV treatment was started in 2005. Currently over 900 individuals receive free HIV medicines and tests from 9 public and 3 private sector facilities.