Pakistan sitting on a ticking AIDS bomb
06 October, 2006
By Amir Latif
She exudes confidence. Confidence of a person who senses that she is doing a great job for her people and the country. She is one of a very few people who are paying the price for a crime, which they never committed, but instead of surrendering to the injustices of life, they try to save others from those injustices.
Shukria Gul, the first woman with HIV in Pakistan to come out publicly and campaign on behalf of fellow sufferers, now counsels those who have nowhere else to turn.
She contracted the disease from her husband who received a contaminated blood transfusion and later died.
The doctors treated me as if I had an illness you get from just touching people. In my neighbourhood people started pointing at me, saying ‘she’s the one with Aids’.”
Shukria set up one of Pakistan’s few direct support groups and her experience has made her highly critical of government departments dealing with HIV. “They give money to agencies who do nice work on paper. Maybe they do work but I haven’t seen any of it on the ground.
“Aids will never be contained unless small grassroots groups like mine are supported, so we can spread the message of prevention by direct contact.”
Though, HIV is not a dominant epidemic in the adult population of Pakistan, coupled with the extremely low awareness of HIVIAIDS in Pakistan, as well as growing number of cases, the AIDS epidemic is poised to take a hold in Pakistan. The presence of additional risk factors such as unscreened blood, and low condom use rates make the situation fertile for AIDS to become a major public health issue.
The National AIDS Programme’s latest figures show that around 3,000 HIV cases have so far been reported since 1986, but UN and government estimates put the number of HIV/AIDS cases between 70,000 and 80,000 with the vast majority going unreported due to social taboos about sex and victims’ fears of discrimination, officials said.
Pakistan is a good example of a country that is learning fast but late about the threat of HIV/AIDS. Unlike India, recorded prevalence in Pakistan is small and the authorities are working to keep it that way. However, there are still plenty of complaints that government departments and NGOs have done little to help those infected or indeed have any idea of the full extent of the problem.
Since 1987, the numbers of reported HIV infections and AIDS cases in Pakistan have risen steadily and affect all geographical regions of the country. The total number of reported cases by September 2006 was 2,998. However, the WHO/UNAIDS forecast model estimates a much higher number: between 70,000 and 80,000 people or 0.1 per cent of the adult population. Hetrosexual transmission (52.55 percent) and contaminated blood or blood products (11.73 percent) are the most commonly reported modes of transmission for HIV/AIDS in Pakistan. Other modes of transmission include injecting drug use (2.02 percent), male-to-male or bisexual relations (4.55 percent), and mother-to-child transmission (2.2 percent). Mode of transmission in 26.9 percent of the reported HIV/AIDS could not be established. The male-to-female ratio is 42:6 and 7:1 (per 100,000) in reported HIV-positive and AIDS cases, respectively. Limited available research indicates that HIV prevalence is one percent to two percent in vulnerable or high-risk populations such as female sex workers and long-distance truck drivers.
The first case of AIDS in a Pakistani citizen was reported in 1987 in Lahore. During the late 1980s and 1990s, it became evident that an increasing number of Pakistanis, mostly men, were becoming infected with HIV while living or traveling abroad. Upon their return to Pakistan, some of these men subsequently infected their wives who, in some cases, passed along the infection to their children. In 1993, the first recognized transmission of HIV infection through breast-feeding in Pakistan was reported in the city of Rawalpindi. During the 1990s, cases of HIV and AIDS began to appear among groups such as sex workers, drug abusers and jail inmates. The increased rates of infection among these groups are assumed to have facilitated, at least to some extent, a further dissemination of HIV into the general population.
Currently classified by WHO/UNAIDS but high-risk country for the spread of HIV infection, Pakistan has recently witnessed changes in the epidemiological trends of the disease owing particularly to rapid rise in infection among injecting drug users.
According to UNAIDS estimates, some 70,000 to 80,000 persons, or 0.1 percent of the adult population in Pakistan are infected with HIV although cases reported to the National AIDS Control Programme are less. As in many countries, the numbers may be underreported—mainly due to the social stigma attached to the infection, limited surveillance and voluntary counseling and testing systems, as well as lack of knowledge among the general population and health practitioners.
Data analysis indicates that most infections occur between ages of 20-44 years, with men outnumbering females by a ratio 5:1. The trends are closely similar to other countries affected by HIV/AIDS. By September 2006, sexual transmission accounted for the majority of reported cases (67.48 percent). Other modes of transmission include infection through contaminated blood and blood products (6.99 percent); injecting drug abuse (0.82 percent); and mother to child transmission (three percent).
The mode of transmission remains unknown in 20 percent of the reported cases most probably due to stigma and lack of awareness. But given the combination of high levels of risk behaviour and limited knowledge about AIDS among drug injectors and sex workers in Pakistan, experts warn that the country could be on the verge of a serious epidemic.
Situation updates in 2005 by various agencies such as the UNAIDS report an “outbreak” of HIV among injecting drug users in Larkana, Sindh, where out of 170 people tested, more than 20 were found HIV positive.
In Karachi, a 2005-06 survey of Sexually Transmitted Infections among high risk groups found that more than one in five Injecting Drug Users (IDUs) was infected with HIV. These represent the first documented epidemics of HIV in well-defined vulnerable populations in Pakistan.
The Enhanced HIV / AIDS Programme aims to “prevent HIV from becoming established in vulnerable populations and spreading to the general adult population, while avoiding stigmatization of the vulnerable populations”. Following are the factors for vulnerability to AIDS:
High risk behaviour among IDUs
IDUs are at a high risk of acquiring HIV and other blood-borne infections because they often resort to unsafe practices such as needle and syringe sharing. Pakistan is a major transit and consumer country for opiates from neighbouring Afghanistan, the world’s largest producer of opium.
As far back in 1999 the United Nations Office of Drugs and Crime had conducted studies in Lahore that revealed that addicts were switching methods of drug ingestion – moving from smoking or “sniffing” or inhaling to injecting polydrug cocktails. This, the UNODC had warned could lead to increase in HIV as needle sharing and use of non-sterile equipment was common . The number of drug dependents in Pakistan is currently estimated to be about 500,000, of whom an estimated 60,000 inject drugs. It is also unlikely that outbreaks which have been witnessed in 2004 and 2005 are likely to be contained or limited to one area. Many of these injectors move from city to city (21 percent of the Karachi users had also injected in other cities) and a very high proportion of them use non-sterile injecting equipment (48 percent in Karachi had done so in the week before the survey was conducted).
Risk behaviour in Lahore is even higher: 82 percent of injectors had used non-sterile syringes in the previous week, 35 percent did so all the time, and 51 percent had injected in another city in the previous year, according to Pakistan’s Ministry of Health.
An HIV epidemic among injecting drug users was reported in 2004 in Sindh, in the town of Larkana where almost 10 percent of drug injectors tested HIV-positive. Knowledge of HIV among injectors (and sex workers) is extremely low. In Karachi, Pakistan’s main trading city, more than one quarter had never heard of AIDS and many did not know that using non-sterile injecting equipment could result in infecting them with HIV, according to Ministry of Health’s findings.
Unsafe Practices among Sex Workers
Female sex workers (FSWs) and female migrant workers are often exploited and abused, and have little recourse due to their low social status and limitations in legal protection. Commercial sex is prevalent in major cities and on truck routes. Behavioral and mapping studies in three large cities found a sex workers population of 100,000 with limited understanding of safe sexual practices. Furthermore, sex workers often lack the power to negotiate safe sex or seek treatment for STIs.
Recent findings indicate that although HIV prevalence remains below one percent, FSWs and their clients report low condom use. Less than half the FSWs in Lahore and about a quarter in Karachi had used condom with their last regular client. In Karachi, one in five sex workers cannot recognize a condom, and three-quarters do not know that condoms prevent HIV (in fact, one third have never heard of AIDS), reports UNIADS Update 2005.
It is therefore little wonder that only two percent of female sex workers said they used condoms with all their clients in the previous week. In addition to the lack of knowledge and low use of condoms, there is a high degree of sexual interaction between drug injectors and sex workers.
Ministry of Health findings reveal that over 20 percent of female sex workers in Karachi and Lahore had sold sex to injecting drug users and condom use was very low during those encounters. Among injecting drug users in Lahore, almost half had had sex with a regular partner in the previous year, one third had paid for sex with a woman (11 percent used a condom consistently) and almost one quarter had paid for sex with a man (five percent used a condom consistently) . Male sex workers also trade sex with injectors, 20 percent of whom reported buying anal sex in the previous year (and only three percent of them used a condom consistently).
Men who have Sex with Men (MSM)
While there is little documentation about the extent to which men engage in sexual activity with other men in Pakistan, the limited evidence available suggests that such activity does occur throughout the country.
Anecdotal evidence indicates that sexual activity between men occurs relatively frequently in boys’ hostels and jails; additionally, research suggests that sex between men is often practiced among long distance truck drivers. Finally, there is a small but highly mobile population of transvestites, transsexuals and eunuchs known as the hijra, who are known to engage in unsafe sexual practices. Lahore had an estimated 38,000 MSM in 2002. The MSM community is heterogeneous and includes Hijras (biological males who are usually fully castrated), Zenanas (transvestities who usually dress as women) and masseurs. Many sell sex and have multiple sexual partners.
Inadequate Blood Transfusion Screening and High Level of Professional Donors
The collection and transfusion of blood and blood products, the use and re-use of unsterilized medical instruments (especially needles and syringes) and the generally low level of attention to standard infection control procedures are important potential avenues for the spread of HIV in Pakistan’s general population.
The indiscriminate use of blood transfusions and of needles in both formal and informal health sectors is common. In addition, standard procedures for infection control in health care settings are often not strictly followed.
A relatively high prevalence of both hepatitis B and C infection in the general population suggests that unsafe blood transfusion practices and poor infection control are likely to make a significant contribution to the further rapid spread of these infections and of HIV/AIDS among the general population.
It is estimated that 40 percent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. In 1998, the AIDS Surveillance Centre in Karachi conducted a study of professional blood donors.
The study found that 20 percent were infected with Hepatitis C, 10 percent with Hepatitis B, and one percent with HIV. About 20 percent of the blood transfused comes from professional donors.
Migration can create conditions in which people become vulnerable to infection. It is commonplace in Pakistan for men to travel away from their homes to find work, either within the country or abroad. This separation from their spouses, families and communities can result in loneliness and isolation, and can lead migrants to engage in social and sexual practices that put them at risk of exposure to HIV.
In addition, though there is virtually no documentation of the HIV/AIDS-related risks experienced by the large number of refugees in Pakistan, global experience suggests that this population may be highly vulnerable to HIV.
Large numbers of workers leave their villages to seek work in larger cities, in the armed forces, or at industrial sites. A significant number (around four million) are employed overseas. Away from their homes for extended periods of time, they become exposed to unprotected sex and are at risk for HIV/AIDS.
Studies indicate that 94 percent of injections are administered with used injection equipment. Use of unsterilized needles at medical facilities is also widespread. According to WHO estimates, unsafe injections account for 62 percent of Hepatitis B, 84 percent of Hepatitis C, and three percent of new HIV cases.
Personal awareness and knowledge of reproductive health issues is limited, and often erroneous, among men and women of Pakistan due in part to the generally low levels of education, and also due to their limited access to effective reproductive health services.
Men and women alike are often unaware of the differences between reproductive and sexual “health” and reproductive and sexual “disease”. When they do become aware of a possible sexual or reproductive problem, they often seek care from traditional healers (hakims) or from one of the many unregulated “sex clinics” in the informal health sector.
In addition, it is estimated that only 60 percent of the country’s population have access to the formal healthcare system and many (through personal preference or necessity) resort to the use of hakims or traditional healers.
It is not uncommon for clinics in villages to be operated by self-described “doctors” who may actually have little or no formal medical training. This reliance upon unqualified practitioners may compound the risk of further infection due to their lack of knowledge and the possibility of inadequate infection control during their therapeutic procedures.
Health care professionals generally believe, however, that the incidence of STIs in Pakistan may be increasing due to the relatively widespread presence of risk behaviors. The 2004 STI survey found that four percent of MSMs in Karachi were infected with HIV, as were two percent of the Hijras in the city.
Syphillis rates were also high with 38 percent of MSMs and 60 percent of Hijras in Karachi infected with the disease. As a consequence, sexually-transmitted infections rates are high: in Karachi, 18 percent of injectors were found to be infected with syphilis, as were 36 percent of male sex workers and 60 percent of Hijras or transgender persons.
Gender inequalities may also play a facilitating role in the further spread of HIV/AIDS in Pakistan. Pakistani women in general have lower socio-economic status, less mobility and less decision-making power than men, all of which contributes to their HIV vulnerability. For example, because of gender disparities in educational enrolment, the female literacy rate in Pakistan is much lower than that of males (35 percent for women as compared to 59 percent for men).