HIV outbreak in Pakistan draws attention to major failures in healthcare system

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Download PDF An outbreak of HIV among children in Pakistan that began in April, in the province of Sindh, has caused outrage in the country and attracted worldwide media attention. So far more than 600 people, more than 80% of whom are children, have been infected with HIV most likely due to unsafe use of syringes, intravenous drips and unsafe…

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More than 600 people, mostly children, infected through unsafe medical practices

ABSTRACT In April, hundreds of children in Pakistan were infected with HIV through the use of unsterile syringes and intravenous drips. Pakistani authorities initially said that the outbreak was traceable to the practice of a single doctor, who was arrested and taken into custody, but public health experts believe his practice to be only a part of the cause. The outbreak has shone a spotlight on what are thought to be widespread unsafe medical practices in the country. The Global Fund is the only provider of ARVs in Pakistan, and the surge in new infections has urgently increased the need for pediatric antiretrovirals.

An outbreak of HIV among children in Pakistan that began in April, in the province of Sindh, has caused outrage in the country and attracted worldwide media attention. So far more than 600 people, more than 80% of whom are children, have been infected with HIV most likely due to unsafe use of syringes, intravenous drips and unsafe blood transfusions.

The first signs of the outbreak happened in the village of Ratodero, a small town in southern Pakistan. A local doctor, treating a small number of families who had brought their children for treatment of persistent fevers, sent blood samples from the children for diagnostic tests after they didn’t respond to medical treatment. On April 24, this first batch of HIV-test results showed that 15 children were HIV-positive – but none of their parents were.

The health department of Sindh province then set up a special camp to offer free HIV screening at a local government hospital. One month later, a senior advisor to the Pakistan health ministry said at a press conference that of more than 21,000 people who had been screened up to that point, 681 people had tested positive for HIV, 537 of them children between the ages of two and 12.

As of June 23, Pakistan’s National AIDS Control Program (NACP) reported that 29,158 people had been screened since 25 April. Of these 831 were ‘suspected HIV-positive – 685 children and 146 adults – and to date 548 children and 114 adults have been confirmed as HIV-positive and connected with HIV treatment centers.

The consensus among medical experts seems to be that, given the parents’ HIV-negative status, the mode of transmission must have been caused by the unsafe practice of using one syringe for many patients. UNAIDS, citing Pakistan’s own government reports, said that around 600,000 ‘quack’ doctors are practising across the country, around 270,000 of these in Sindh province.

In early June, the Washington Post described the outbreak as spreading “anxiety throughout a country already confronting distrust in its health system and skepticism of its immunization programs”. In mid-June, Al Jazeera reported that Pakistan was facing a lack of sufficient anti-retroviral drugs to treat those affected.

Global Fund is Pakistan’s sole provider of antiretroviral treatment

The Global Fund currently provides antiretroviral therapy for 17,149 people in Pakistan, out of the 165,000 people in the country who are estimated to be HIV-positive (nearly half of whom live in Sindh province, according to UNAIDS).

The Fund Portfolio Manager for Pakistan, Werner Buehler, told the GFO in an email that when the outbreak occurred (in April), that there weren’t enough pediatric ARVs in stock in Pakistan to put all the children who had been newly diagnosed with HIV on treatment, so physicians had to establish priorities for treatment based on patients’ CD4 counts.

Officials from Pakistan’s national AIDS program (NACP) told the Global Fund that it had enough pediatric ARVs in stock to cover 300 children and continue them on treatment until July 2019, but did not have enough stock to cover another 300 children. Immediately after, Buehler said, the NACP placed two urgent orders with the Global Fund for pediatric ARVs. (The Global Fund is currently the only source for antiretroviral treatment in Pakistan.)

“The Global Fund promptly confirmed availability of the drugs with manufacturers, and the process to have those delivered to Pakistan is underway,” Buehler said, adding that the lead time for procurement is determined mostly by the logistics related to shipping and obtaining the necessary waivers from the Pakistan’s government. This emergency order for treatment adequate for 600 additional children is due to arrive in Pakistan in the first week of July.

The NACP has placed an additional emergency order for treatment for 1000 children that is expected to arrive in the country at the end of July. Given the overall state of ART stocks and this pipeline, the NACP “doesn’t see an alarming situation that cannot be handled by PSM,” the Global Fund told the GFO.

Buehler said that the Global Fund is currently in talks with the Government of Pakistan, UNAIDS and WHO, “to possibly reorient our HIV grant towards the priorities which now emerge as a consequence of the Larkana outbreak”. These include HIV sentinel sites, systematic opt-out testing outside of high-risk groups, and increased procurement of ART.

2016 HIV outbreak in same part of Pakistan

A similarly sudden outbreak of HIV occurred in Sindh province in 2016, when more than 1500 people were found to be HIV-positive in an unusual surge in positive HIV test results after thousands of people were tested. At that time, most of the newly infected people were men, and the cause was linked at the time to sex workers in the area, 32 of whom were found to be HIV-positive.

UNAIDS has said that the HIV epidemic in Pakistan (once considered a low-prevalence country) is expanding, with the numbers of young people who are HIV-positive increasing by almost 30% between 2010 and 2017.

The Global Fund has funded five HIV/AIDS grants in Pakistan to date, with a total investment of more than $300 million since the first Global Fund grants began there in 2003.

Further reading:

• Pakistan’s National AIDS Control Program
• BBC News’s article from 21 May 2019
• The Washington Post’s article from 6 June 2019 on the Larkana outbreak
• Al Jazeera’s article from 16 June 2019