Electronic Health interventions for HIV in Pakistan: Is it the only way out?

HIV incidence is decreasing globally. Amongst the countries in the Asia-Pacific region, a 31% decrease in HIV incidence was reported between 2000 and 2014. ¹ Despite these decreasing trends globally and within the region, the incidence in Pakistan has been on the rise. The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that the prevalence of HIV doubled in Pakistan in 13 years, as there were 97,000 adult people living with HIV (PLWH) in Pakistan in 2009 (0.1% prevalence) and 210,000 PLWH in 2022 (0.2% prevalence). ² The trends are alarming as there has been an overall 84% increase in HIV cases during the same period. ³

Pakistan has been a victim of frequent outbreaks every few years. The country has experienced at least seven outbreaks between 2000 and 2019, and has registered four major outbreaks since 2018. ⁴ Most of the outbreaks are reported in the rural areas of the country where low literacy, high poverty, and a fragile healthcare system limits diagnosis and undermines attempts to break the cycle of disease spread.

Much of the HIV incidence in Pakistan is attributed to intravenous drug use, barbers reusing razor blades, unsterilized dentistry tools, and reuse of syringes in unregulated healthcare facilities. ⁵ These numbers represent the tip of the iceberg. Much of the HIV burden remains undetected and unreported due to the cultural and religious taboos associated with HIV diagnosis. This not only prevents diagnosis, but also hinders diagnosed patients in seeking treatment and following up with their healthcare provider.

The UNAID’s goal for Pakistan was to achieve 90-90-90 status by 2020, where 90% of PLWH know their HIV status, 90% of those receive antiretroviral therapy (ART), and 90% of ART recipients are virally suppressed. According to the estimates and reports from the National Aids Control Program (NACP), Pakistan currently seems to stand at 23-7-4, an alarming distance away from the 90-90-90 goal by 2020, and even farther from the 95-95-95 goal by 2030. ² Even though the goals seem elusive, Pakistan needs to act promptly, and discreet efforts must be taken to bridge the gap between goals and the current situation.

Globally, countries are using a variety of methods for HIV prevention and improved testing and management. Electronic health, or eHealth, interventions have emerged as a promising tool being utilized for HIV prevention, testing and management. EHealth interventions include a wide variety of interventions utilizing internet, computer, or mobile phones and could take the form of websites, software, applications, email, video games, telemedicine, text messaging, and social media. Multiple forms are used in combination to achieve desired results.

Bourne et al. reported that SMS reminders to HIV-negative men having sex with men (MSM) in Australia were 4.4 times more likely to re-test for HIV compared to the group not receiving SMS. ⁶ Uzma et al. reported that weekly phone call reminders, coupled with patient involvement in cue-dosing, resulted in significant improvement in ART adherence and virological outcomes. ⁷ Perera et al. used a smartphone application in New Zealand where participants received daily graphical estimates of plasma concentrations of ART and reported significantly higher adherence scores compared to the control group. ⁸ These studies not only report increased HIV testing and linkages to care, but also improved treatment adherence. A systematic review of the use of eHealth interventions for HIV treatment and care in the Asia-Pacific region only reported one study from Pakistan. ⁹

Pakistan ranks 10^th globally in mobile usage and has the highest mobile penetration rate in South Asian region with approximately 90% Pakistani’s living in areas with cell phone coverage. As of January 2023, there are 192 million mobile connections in Pakistan, which equates to more than 80% of the country’s population. ¹⁰ Electronic usage is on the rise, with 80% population using a smart phone, and 75% population with access to the internet. ¹¹ Pakistan is also the 7^th largest population of internet users in the world with 140 million internet users and 57.6 million Facebook users, accounting for 25.1% of the entire population. ¹²

Engaging this huge chunk of population using different eHealth interventions for HIV prevention, testing and management can provide lasting benefits in the country’s battle against HIV. Mobile phone- and internet-based interventions can be used to reach far flung areas that are otherwise difficult to reach physically. A basic framework of disease education via SMS and social media campaigns, and increased testing and self-reporting via basic online apps can significantly change the numbers in our favor.

Despite the miserable current situation, efforts must be invested where the potential for benefit is the highest. The 23-7-4 represent three stages of HIV management, that include diagnosis, treatment, and follow-up. Utilizing the vast cell phone and internet coverage, eHealth interventions can influence all three stages of HIV management and even though the 2030 goal seems improbable, large and meaningful strides can be made to bridge the gap.