The discovery of an HIV outbreak among hundreds of children in Pakistan has spurred an international response and put a spotlight on healthcare and treatment practices in a country already facing a fast-rising epidemic.
This month, the World Health Organisation started rolling out a $1 million emergency response, but medication shortages are already posing a challenge as responders try to contain the outbreak.
More than 800 people – over 80 percent of them children – have tested positive for HIV since April in Larkana district, north of Karachi, according to Dr. Sikandar Memon, project director for the provincial government of Sindh’s AIDS control programme.
Health officials say poor infection control, including the re-use of syringes, may be the primary cause of the outbreak. Local officials initially pointed a finger at a single doctor who worked with children.
But medical experts say the problem may be more widespread, underscoring a lack of public awareness about HIV risks and prevention methods in Pakistan, which has the second-fastest-rising HIV epidemic in Asia and the Pacific after the Philippines, according to UNAIDS.
The WHO is treating the outbreak as a Grade 2 emergency, indicating “moderate” public health consequences – the same internal classification used for aid agency efforts for Cyclone Idai in southern Africa and in Afghanistan, where aid workers struggle to bring healthcare to hundreds of thousands of people displaced by conflict.
Its plan, which will be carried out with the government, NGOs, and other UN agencies, calls for resources to treat up to 5,000 patients in Larkana, screen as many as 150,000 people, and reach 1.5 million people in the wider community with HIV education.
But the surge in new cases means there’s a sudden shortage of the paediatric antiretroviral medication used to treat HIV in children. Before the Larkana outbreak, only 1,200 children in Pakistan were being treated for HIV, according to the WHO.
As of this week, less than half of the newly diagnosed people in Larkana were receiving treatment. Last week, the WHO warned that there was only enough antiretroviral medication for 240 children through mid-July.
“This means that only nine more children can be enrolled for treatment using available stocks, leaving many other children who have tested positive without treatment,” the agency warned last week.
The government’s AIDS control programme says it has placed urgent orders for new stocks of paediatric antiretrovirals. The Global Fund to Fight AIDS, Tuberculosis and Malaria, which is facilitating the order with drug manufacturers, told The New Humanitarian that new supplies should be delivered by the first week of July.
Memon said three new treatment facilities, including one in the Larkana town of Ratodero, will be able to treat 1,000 patients free of charge.
“There is a huge amount of work that needs to be done to improve infection control and support the affected children and their families,” said UNAIDS regional director Eamonn Murphy.
Pakistan’s HIV rate has been on the rise for more than a decade: the country had some 20,000 new HIV infections in 2017, and estimates for treatment coverage rates – as well as the number of people with HIV who know their status – fall below regional averages.
Local media first began reporting a jump in HIV cases among children in Ratodero in April.
Hundreds of new cases were later revealed in Larkana after the provincial government set up blood-screening camps to test for HIV. Memon said some 28,000 people have been screened so far.
Authorities are still investigating what caused the outbreak, but their initial findings suggest the primary cause may be risky practices like the re-use of syringes and poor standards for blood transfusions.
Some medical experts say such behaviour is rampant in Pakistan’s health sector, where there has been a proliferation of poorly trained doctors practising in rural and suburban areas.
Dr. Ali Azhar, general secretary of the Pakistan Medical Association, said the quality of medical education in his country has deteriorated, and authorities have failed to rein in unlicensed doctors. Containing the ongoing outbreak, he said, “requires a very big crackdown on quacks and blood banks”.
This crackdown on unlicensed “informal medical practices” has already begun, according to UNAIDS, with the Sindh government shuttering 900 clinics and blood banks.
Stigma and education
The WHO and other agencies are supporting a public health information campaign: while doctors and nurses will be trained in HIV case management, 1,000 health workers will be taught health promotion and stigma reduction.
Meanwhile, families of children recently diagnosed say they are already facing discrimination in their communities.
“The relatives have ceased visiting us affected families. They have even quit mingling, eating, and drinking with us.”
A 23-year-old father told TNH his son was one of two dozen children diagnosed with HIV in his village near Ratodero.
“The relatives have ceased visiting us affected families. They have even quit mingling, eating, and drinking with us,” said the father (unnamed to protect the identity of his son).
Most of his neighbours, he said, don’t understand how HIV is spread, or that it can be managed with treatment.
A 2013 countrywide survey carried out by the government and the UN found that only half of respondents had heard of HIV, and only 13 percent could name the ways in which the virus is transmitted: through blood transfusion, unprotected sex, the use of contaminated needles, or transmission from mother to child.
UNAIDS has said many Larkana parents first learned about HIV when their children were diagnosed. Health experts say this underscores the need to rapidly improve HIV awareness and education, in addition to responding to the outbreak itself.
“That needs a radical approach on the planning level," said Dr. Bushra Jamil, associate professor and head of the infectious diseases section at Karachi’s Aga Khan University.
She said a large-scale awareness campaign would need to include influential religious clerics if it is to have a wide enough reach.
“The majority of the people are religious-minded and they are very receptive to what a cleric says,” Jamil said.
(TOP PHOTO: Staff at a hospital in Ratodero prepare blood tests for residents who rushed to the facility after an HIV outbreak in the town and surrounding villages.)