HIV is an emerging health challenge in Pakistan: risk factors and management strategies

Dear Editor,

Despite promising global progress against HIV, children are a major target of the HIV epidemic, with 2.8 million infected worldwide, out of a total of 38.9 million. Owing to insufficient access to treatment and care facilities, in 2018, 980 children were infected daily with HIV and 320 died daily because of AIDS. ¹ A combination of strategies using biomedical, behavioural and structural approaches has reduced HIV infections in many countries. According to UNAIDS, globally >300,000 people have had pre-exposure prophylaxis for the prevention of HIV in 2018. ²

In recent years, major outbreaks of HIV were reported from all provinces in Pakistan. ³ This infection still remains a major health concern in Pakistan, as it has been for decades. On average, Pakistan registers 20,000 new cases of HIV per year, ⁶ while a 45% increase in HIV infection has been reported from 2010 to 2017, ⁴ giving Pakistan the unfortunate distinction as being the second largest region of the growing AIDS epidemic. According to 2019 estimates of the National AIDS Control Program (NACP), 165,000 people in Pakistan are HIV-positive, of whom only 36,902 are registered with the NACP, and 20,994 receive anti-retroviral therapy (ART), with 6426 using injectable drugs (PWID) along with the ART. ⁵

In January 2019, a total of 5000 individuals were PCR screened for HIV out of which 699 were positive from Kot Imrana village, district head quarter (DHQ) hospital, Sargodha. Its prevalence has increased tenfold from 1.25% in June 2018 to 13.38% in January 2019. Children and women were highly affected with HIV among screened individuals. There are 900 carriers of HIV living in Sargodha. ⁶ According to, the genome Centre for Molecular Based Diagnostic and Research, Lahore (GCMBDRL); Lahore, Sheikhupura, Faisalabad and more than 50 villages of Sargodha and Multan are potential hotspots of HIV in Pakistan. ⁶

In Larkana, a district of Sindh, 37,558 people were screened for HIV from 25 April to 30 November 2019, of whom 754 children and 141 adults tested positive. ⁷ Since 2003, this has been the fourth major outbreak of HIV in Larkana. ⁸ In May 2019, an outbreak of HIV occurred in Gujrat, Punjab, where 2000 people were found positive for HIV including 120 children. Indeed, if HIV continues to spread at this rate in Pakistan, then the situation will be no different from Nigeria and South Africa, probably as soon as 3–5 years. ⁹

Ignorance and anxiety concerning HIV have produced a great deal of bigotry against people who are living with HIV. Violence against women and girls, gender inequality and the exclusion of populations with the highest risk of developing HIV infection (sex workers, prisoners, people who inject intravenous drugs and homosexuals) predated the HIV epidemic by decades. ²

In the case of Kot Imrana village, 96% of patients confirmed a lack of awareness about the transmission and consequences of HIV. Later, it was found that a quack (traditional healer), who died of AIDS in 2018, was using contaminated syringes and was responsible for transmitting the infection to hundreds of patients. In Sargodha, 5000 quacks who practise there may be exposing patients because of unsafe practices. Furthermore, barbers using contaminated razors and blades may also be responsible. ⁶ Other routes of infection include blood or plasma transfusion, piercing of the ears and nose, tattooing and male circumcision with unsterile blades.

The transfer of powers to the provinces from Health Ministry in 2020 has resulted in weak cooperation among federated units, underreporting and misclassification of cases of HIV, a lack dedication of Health authorities with varying disparate HIV interventions and a lack of constructive community meeting. Unhealthy, unsafe and unhygienic medical practices by unqualified and unskilled individuals persist. ¹⁰

There is a deficiency of antiretroviral drugs generally; only 27 treatment centres have been established in all four provinces of Pakistan and only 22 community-testing centres, which are home-based, are currently working in the country. Hospitals do not even have a budget to buy or import test kits whose cost is high (US$15), though free testing was established in three cities: Lahore, Karachi and Islamabad. ⁵

Despite efforts, HIV treatment is not available to 147,851 people in Pakistan. ² Nonetheless, a new ART clinic for children has been established in Larkana; ¹¹ however, its financial support in the country is unlikely to be guaranteed. While these are significant steps, prevention is always better than cure, and this must be linked with the awareness of the general public.