This is the third HIV outbreak in Larkana and this time is has taken place among a low-risk group, children, which is why the government needs to train a paediatrician there and ensure they get the medicines.
From the information that is available, in the third week of April a local general practitioner of Ratodero saw children with persistent weight loss or fever. He sent 11 for HIV testing to a government-contracted centre managed by the PPHI. The blood samples of these 11 children were later sent to a referral laboratory of the Sindh AIDS Control Programme for confirmation where five to six of them were found to be HIV-infected. None of their parents were infected, excluding the possibility of mother-to-child transmission.
Mishandling of the situation
Once the news of this unusually high number of HIV-infected children broke out, it was a media frenzy and the local health and district administration panicked and took unscientific measures, such as jailing a trained MBBS physician on suspicion of intentionally infecting the children.
There are set guidelines available one click away to handle any disease outbreak. Obviously, they weren’t looked upon. It is now suspected that the infection among these children was transmitted by untrained health care providers or quacks practicing in Ratodero, possibly through the reuse of injection equipment which could include reusing syringes or IV lines (drip sets) on multiple patients.
Pakistan is notorious for unsafe injection practices and multiple sound studies have established that a majority of hepatitis C and hepatitis B infection in the country has been transmitted because of the reuse of injections in rural and urban settings.
What measures should be taken now
It must be ensured that HIV medicines (paediatric doses) for these children are available at the ARV Centre in Larkana. Once a person is infected with the HIV virus she/he needs to start taking medicines called anti-retroviral (ARV) drugs immediately and for the rest of their life.
There is no trained paediatric HIV physician in Larkana. It is the government’s responsibility to immediately arrange training for a paediatrician who is based in Larkana and can deal with these children so the children do not have to come to Karachi to seek treatment.
These children are possibility from poor and less educated families. They need to be counselled and educated on how to deal with the HIV stigma and how to take care of their children.
These children will require nutritional support and if their parents/guardians cannot afford it, support from institutions such as the Pakistan Baitulmal or any other should be immediately identified.
It is the government’s (local administration) responsibility to curtail quackery. The local administration and Sindh Health Care Commission should take honest and lasting measures to stop this menace.
Blood banks in the area selling unscreened blood should be shut down by the Sindh Blood Transfusion Authority and the local administration.
The Sindh AIDS Control Programme has to provide HIV prevention services to high-risk people in Larkana as soon as possible in order to reduce the risk of HIV transmission.
These are not extraordinary measures. They are steps that should have been taken in the political heartland of the current government but unfortunately this is not the case. One can only imagine what is going through the minds of the parents of these small children who have been infected with HIV to no fault of their own. Their lives have been changed for the worse.
High risk groups in Pakistan
The first outbreak of HIV in Pakistan occurred in 2003 in Larkana among people who inject drugs. The second one happened in 2016 among patients receiving dialysis at Larkana’s teaching hospital’s dialysis unit. This is the third HIV outbreak.
The high risk groups for HIV in Pakistan are people who inject drugs, transgendered or hijra sex workers and male and female sex workers. HIV infection has been found to be present in dangerously high numbers in all of these risk groups in all major cities of Pakistan.
In Sindh, Karachi has the highest number of HIV-infected high risk group people and the second city for this in the province is Larkana.
History of HIV in Larkana
The results of the last HIV national surveillance round of 2016-2017 indicated that HIV infection in Larkana was:
Hijra sex workers 14.2%
Male sex workers 3.1%
Female sex workers 2.5%
These are astounding numbers for a district whose population is approximately 1.5 million. In Larkana, near the Jatoi Mohalla there is a functioning brothel. On main Station Road there are small motels or sarae khanas where an interested person can easily find hijra or male sex workers for 100 to 200 rupees. Condom use rates are abysmal among these high-risk groups. PWIDs are present in abundance near the main graveyard or Abu Bakar Maqam.
What you need to know about HIV
There is a different between HIV and AIDS. HIV stands for human immunodeficiency virus. AIDS stands for acquired immunodeficiency syndrome.
HIV is the virus that causes HIV infection and AIDS is the advanced stage of HIV infection. Symptoms such as fever, weight loss, generalised weakness and irregular diarrhoea show up in an HIV-infected person.
HIV can be transmitted through blood and body fluids and a mother’s breast milk. However, HIV is usually spread by having unprotected sex (i.e. sex without using a condom), injecting drugs with a syringe used by multiple persons, using a used syringe in health care settings on more than one patient.
The transmission of HIV is very efficient if HIV-infected blood is transfused to a patient. The HIV infection cannot be transmitted by casual contact with an HIV-infected person such as sitting together, shaking hands, hugging, using the same toilet seats or dishes. HIV cannot be transmitted by mosquito bites.
HIV is a lifelong illness. The HIV-infected person’s immune system becomes weak and they become susceptible to other infections such as TB or pneumonia. Once a person is infected with the HIV virus they need to immediately start taking medicines called anti-retroviral (ARV) drugs for the rest of their life.
Treatment of HIV also requires regular follow-ups to determine how the virus is behaving in the person’s body and if there are any signs of other infections which may require additional medicines. An HIV-infected person also has eat a proper diet. If a husband is infected with HIV and the wife is HIV-negative the couple will have to practice safe sex by using a condom. In situations when a couple does not have children and one partner is infected with HIV but they want to have a child, it is now possible with the advent of new HIV treatments called ‘pre exposure prophylaxis’ or PrEP. However, it is not as easy as it sounds and it should be tried under proper medical supervision of an HIV physician.
HIV in Pakistan
Mathematical models of UNAIDS estimate that there are 160,000 HIV-infected people in Pakistan. The treatment for HIV is provided free of cost by the government’s National and Provincial AIDS Control Programmes and their designated treatment centres. HIV testing is also freely available at many testing centres. The website of the National AIDS Control Programme (http://www.nacp.gov.pk/) indicates that there are about 16,000 HIV-infected persons in Pakistan receiving treatment.
Dr Arshad Altaf is a public health and HIV expert trained in Pakistan and United States. He works as an international consultant for the World Health Organization in Geneva and WHO Western Pacific Regional Office in Manila.