Sep 24 - 30, 2007

The deadly HIV/Aids pandemic is one of the most searing problems faced by the human race today. Globally, more than 25 million people died of Aids since 1981. The disease is present in Pakistan and poverty and illiteracy have added to its spreading here. The general public is vulnerable due to other risk factors as well. According to the latest United Nations report, in Pakistan 3,000 died of Aids in the year 2005; while around 85,000 are estimated to have contracted the virus. Ironically, only 3200 know that they are HIV positive. The remaining 80,000 plus are not aware of their illness

The first case of Aids was reported in 1987 in Lahore. During the late "80s and "90s, it became evident that an increasing number of Pakistanis, mostly men, were becoming infected with HIV while living or travelling abroad. Upon their return to Pakistan, some of these men subsequently infected their wives who, in some cases, passed the infection to their children. In 1993, the first recognised transmission of HIV infection through breastfeeding in Pakistan was reported in the city of Rawalpindi.

Pakistan however still has a window of opportunity to act decisively to prevent the spread of HIV/AIDS. Although the estimated HIV/AIDS burden is still low-around 0.1 percent of the adult population - there has been an outbreak of HIV among injecting drug users in Sindh. Without vigorous and sustained action, Pakistan runs the risk of experiencing the rapid increase in HIV/AIDS among vulnerable groups seen elsewhere. According to UNAIDS estimates, some 70,000 to 80,000 persons, are infected. Until September 2004, only some 300 cases of full-blown AIDS and another 2300 cases of HIV infection were reported to the National AIDS Control Program. 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 2003, sexual transmission accounted for the majority of reported cases (67.48%). Other modes of transmission included: infection through contaminated blood and blood products (6.99%); injecting drug abuse (0.82%); and mother to child transmission (3%). The mode of transmission remains unknown in 20% of reported cases most probably due to stigma and lack of awareness

Local and international NGOs have made important contributions to the nation's response to HIV/Aids, and have been instrumental in reaching populations that are difficult to access. As very few of these NGOs receive significant donor funding, they generally rely upon self-financing mechanisms or contributions from the communities they serve; thus, their activities are relatively limited in scope.

(1) Base on UNAID analysis

(2) Factors for vulnerability to AIDS are

(3) High risk behaviour among Injecting Drug Users (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. An HIV epidemic among injecting drug users was reported in 2004 in Pakistan's Sindh province, in the town of Larkana where almost 10% of drug injectors tested HIV-positive

(4) Unsafe Practices among Sex Workers

Behavioral and mapping studies in three large cities found a sex workers population of 100,000 with limited understanding of safe sexual practices. Ministry of Health findings reveal that over 20% of female sex workers in Karachi and Lahore had sold sex to injecting drug users and condom use was very low during those encounters.

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.

(5) Men who have Sex with Men (MSM):

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 2005.

(6) 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 unsterilised 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. 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 Center in Karachi conducted a study of professional blood donors. people who are typically very poor, often drug users, who give blood for money. The study found that 20 percent were infected with Hepatitis C, 10 percent with Hepatitis B, and 1 percent with HIV. About 20 percent of the blood transfused comes from professional donors.

Large Numbers of Migrants and Refugees: Migration can create conditions in which people become vulnerable to infection.

Unsafe Medical Injection Practices: Pakistan has a high rate of medical injections - around 4.5 per capita per year.

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 do men, all of which contributes to their HIV vulnerability

Dr Asma Bukhari is the National Programme Manager of Pakistan's National Aids Control Programme (NACP). According to her approach, she says that they are working to prevent an epidemic. No government in the world has been able to control it, but yes, they are making all out efforts to control the spread of this virus. But it is easier said than done. As a blood bank and transfusion resident physician, I personally think that there is a need to join hands to control its spread. In the present scenario, HIV/AIDS prevention and control in Pakistan has gained attention due to donor driven pressure and allocations of large amounts of funding ($40 million USD) through a comprehensive, five-year enhanced HIV/AIDS program (2003 2008) executed by NACP under the leadership of the Ministry of Health (Government of Pakistan) with financial assistance from the World Bank and other bilateral donors such as the Department for International Development (DFID) and Canadian International Development Agency (Canadian CIDA). The contract for the Enhanced Program was signed in 2002. Pakistan does not have a formal HIV/AIDS policy but rather works through a country strategic framework formulated in 1999-2000 with the assistance of UNAIDS and other development partners as well as civil society organizations and PLWHA groups. In fact, it is the NGO sector that is actually implementing major interventions such as working with marginalized groups, harm reduction programs and managing community based Voluntary Counseling and Testing centers (VCT).

There is an assumption on the part of many that the residents of Pakistan will be protected from HIV because they belong to an Islamic society with traditional, conservative behavioral mores. The prohibitions in Islam against sex outside marriage (pre-marital or extra-marital sex) and against homosexuality are perceived as effective defences against HIV by many political, educational, and religious leaders in Pakistan.

Public and governmental recognition of the threat of an HIV epidemic in Pakistan is recent and the implementation of prevention and education programmes pertaining to HIV/AIDS is lagging. The status of being a low prevalence but high-risk country for HIV makes it critical that practical research and HIV-prevention efforts targeted at high-risk groups be implemented immediately. By effectively reaching high-risk groups at this early stage in the epidemic, Pakistan may be able to avoid the need to implement mass population-based HIV prevention (and treatment) programmes.