Special report: The making of an HIV catastrophe

Reasons for new infections, include the lack of political will and the stigma attached to the disease.
Published October 5, 2017

Resurgence of HIV in Pakistan

By: Faiza Ilyas and Ikram Junaidi

KARACHI/ISLAMABAD: In October 2016, it was reported that more than 50 patients on renal dialysis at the Chandka Medical College Hospital (CMCH) in Larkana had contracted the Human Immunodeficiency Virus (HIV).

The Journal of Pakistan Medical Association put the total figure at 56. It was also learnt that 36 patients had contracted HIV and hepatitis C, whereas two tested positive for hepatitis B.

Since, seven patients have died due to complications over the past ten months.

Inquiries into the CMCH incident reveal that most patients had a history of multiple blood transfusions conducted at the hospital; and that private blood banks in the vicinity operate without adhering to quality assurance methods.

Sources at the hospital — which also has an HIV/AIDS care and treatment centre — explain that the dialysis unit prior to the incident did not have a laboratory to screen patients.

Moreover, hospital staff relied on dubious lab reports [for blood tests] that patients brought with them.

Regrettably what might have been an opportunity for action was another episode of official indifference.

When Dawn contacted Dr Hola Ram, in charge of the HIV/AIDS care and treatment centre at CMCH, he confirmed, “The total number [of infected patients] was 50; three to four patients refused to receive antiretroviral therapy, while the rest are on HIV treatment.”

However, last year when the inquiry committee was writing its report, 26 patients were infected with HIV, he said.

Moreover, two out of three blood banks sealed after this incident were later declared ‘safe’ and allowed to operate by the Sindh Blood Transfusion Authority (SBTA).

However, the CMCH, a 1,500-bed tertiary care hospital still does not have a blood bank. Sources at CMCH also told Dawn that the sale of blood by injecting drug users continues unabated in the district.

Donors are clandestinely approached by agents at night mostly to for urgent blood donations.

Source: UNAIDS, National AIDS Control Programme and the Global Fund.
Source: UNAIDS, National AIDS Control Programme and the Global Fund.

Months into the incident recommendations made by the inquiry committee in October 2016 remain unimplemented, including the appointment of a nephrologist at the hospital and the curtailing of sub-standard laboratories.

Also, patients who contracted HIV at CMCH complain that they have not been compensated by the government.

“The incident brought a bad name to the government. Worse still, all those responsible for the HIV outbreak — officials from the Sindh AIDS Control Programme (SACP), the SBTA and even the medical superintendent of CMCH — were part of the inquiry committee,” says a health expert on condition of anonymity.

Dawn repeatedly contacted the SACP manager and the SBTA secretary for their comments but both did not respond.

An investigation report into the Larkana incident by the National Aids Control Programme — which reviewed HIV/Aids treatment centre data at CMCH from February to August 2016 — states that while an average of 29 new HIV patients registered each month at this facility the ratio of those who sought treatment was recorded at 19.4 per cent.

Larkana has witnessed rising numbers of HIV cases since 2003 when the first outbreak among injecting drug users was reported.

At that time, a survey cited 17 out of 175 injecting drug users as HIV positive.

Certain varying factors have also contributed to the rise in HIV in Larkana, including its active population of sex workers, especially male-to-male sex workers, and injecting drug users.

It is unfortunate that in a province where almost half of the country’s HIV infections have emerged, patients are compelled to travel to Karachi that has one HIV referral laboratory.

“The Larkana incident is reflective of how HIV is spreading in the country, especially where regulatory health control mechanisms and treatment are absent.

And, while, unscreened blood transfusions and the lack of infection control practices is common, there is still silence on this,” an infectious disease expert explains.

Karachi is identified as one of the top cities globally with a rise in HIV prevalence

According to medical experts, aside from the fact that HIV infection takes a long while to show signs, physicians’ lack of awareness, the social stigma attached to the disease and the reluctance of government officials to document exact numbers of infected people are contributing factors that veil the truth about the rise of HIV.

In other words, the Larkana incident provides some explanation for the rise in HIV among communities most at risk.

New HIV infections

With about 133,529 people estimated to have contracted HIV, Pakistan is one of few regional countries to witness an increasing number of cases.

Hopes for successfully tackling the disease are overshadowed by extremely low HIV screening and treatment coverage, and rising numbers of new cases.

With the country’s HIV/AIDS control programme about to receive a renewed three-year (2018-2020) $35 million grant from the Global Fund for Aids, TB and Malaria (GFATM) — a financing partnership organization — those registered as HIV positive must be ensured access to free medication and treatment options.

Antiretroviral therapy (ART), a life-saver, stops the virus from making copies of itself and attacking the body’s immune system.

“The reasons for new infections, include the lack of political will, bureaucratic hurdles, the stigma attached to the disease, the absence of treatment and technical facilities and trust deficiency [between implementing stakeholders],” explains Dr Baseer Achakzai, the manager of the National Aids Control Program (NACP).

More alarmingly, the Integrated Biological and Behavioural Surveillance for 2016-2017 by NACP conducted in 23 towns/cities shows that the high prevalence of HIV is no longer confined to injecting drug users and transgenders, but, has taken the form of an epidemic in other high-risk groups as well – prisoners, men having sex with men and male sex workers.

This increase can also be traced to growing numbers among other segments, such as female sex workers, migrant workers returning from the Middle-East as well as those people contracting HIV through unsafe blood transfusions and drips.

With treatment coverage remaining very low, the critical question is whether donor money is equitably distributed.

“The way the HIV/AIDS programme is currently administered in the country is a sheer waste of money,” says former SACP director, Dr Sharaf Ali Shah, who heads the Bridge Consultants Foundation, an implementing partner working with NACP and New Zindagi Trust (NZT) – a non-governmental organisation serving as a principle GF grant recipient since 2011.

Globally, HIV control programmes are integrated with other healthcare strategies. Referring to the lack of free drug rehabilitation centres in Karachi, he explains, “this highly marginalised group of drug users at the core of the HIV epidemic has serious psychological and social issues.

If you don’t address them, they won’t adhere to treatment and that can lead to relapse, resistance against the drugs.

Besides, wives and partners can get infected. We also require proper facilities for detoxification therapy.”

With Karachi identified as one of the top cities in the world with a worrying rise in HIV prevalence, it is critical to control the disease before it spreads further.

High-risk population groups

Sexual transmission among men will account for the bulk of new HIV infections, if intervention remains at current levels, according to UNAIDS.

Moreover, whilst female sex workers have the lowest prevalence among key population groups (2.2pc), their rate is increasing at the fastest pace (up by 2.67pc from 0.6pc in 2011).

Transgender people have the highest overall HIV prevalence rate (7.1pc) among key populations for whom sexual transmission predominates.

The highest prevalence rate for transgenders was reported from Larkana (18.2pc) followed by Bannu (15pc) and Karachi (12.9pc).

In Khyber Pakhtunkhwa (KP), for example, Dawn has learnt that the HIV control programme will begin providing counselling, testing services and treatment to transgenders in July.

According to Dr Ayub Roz, head of KP’s HIV control programme, Rs 200m is available for preventive measures and treatment for transgenders.

With an estimated 9,000 HIV patients, lack of funding had halted the KP Aids control programme.

Although entitled to grant money from the NACP, KP had failed to meet essential requirements – including submitting a PC-I for projects, says Dr Achakzai, though this year funding will be disbursed after GF approval, he confirms.

With Rs300m for the HIV programme, only Rs30m was released in 2016-17 – money spent on offices and hiring staff, say sources.

Meanwhile, the government’s inability to convince stakeholders to allow the use of opioid substitution therapy, a proven intervention allowed by the World Health Organisation and a critical part of the detoxification therapy for drugs users with HIV poses another barrier.

Where is Global Fund assistance going?

Since 2000, GF has contributed 80pc of funding for the country’s HIV program while the government provides 20pc.

According to Tariq Zafar, the executive director of NZT, the trust receives around $5m annually ─ it has received $17.45m over the past three years.

GF has ranked the trust at A2 level which means near 100pc, he says.

Explaining the procedure to qualify for a grant, Dr Achakzai says GF forms a country coordination mechanism (CCM) including representation from concerned ministries, departments and civil society.

“Concept notes are sent from the government and private organizations (NZT) by CCM to GF for approval. NACP transfers funds it receives to the provinces,” he explains.

Similarly, NZT disburses GF money to sub-recipients – three in Sindh, two in Balochistan and similarly, private not-for-profits are provided funding in Punjab and KP.

Without a GF representative in Pakistan, the United Nations Office for Project Services (UNOPS) serves as the local fund agent.

According to Dr Achakzai, it verifies accounts and reports to GF every six months.

“We have observed that the local fund agent raises objections regarding NACP accounts, but ignores discrepancies in private sector accounts,” he claims.

“Often the NACP will face objections over a transaction of Rs 1,300, for example, but bills from the private sector that amount to Rs 1.3m with the same objections are cleared,” he adds.

Sources at NACP also told Dawn that concept notes by NZT are forwarded to GF without detailed evaluation.

On his part, Mr Zafar explains that “although GF sends us money, our concept notes are approved by the secretary for the ministry of national health services.”

He says that a quarterly audit is also conducted, claiming that because NZT conducts a detailed audit of sub-recipients that “they remain annoyed with us.”

Between July 2014 and December 2016, GF contributed $9.023m for Pakistan’s HIV programme.

Out of which $1.3m was spent in Punjab, $0.84m in Sindh, $0.43m in KP and $0.36m was spent in Balochistan. Moreover, $0.2m was also given to the Association of People Living with HIV which has worked in collaboration with the NACP.

Despite these allocations, insider sources say it is a difficult task to get the government to provide funding to the provinces.

And KP’s dormant HIV control programme serves as an example.

Interestingly, though Dr Achakzai says the HIV program has never had financial hiccups, he admits that government funding is rare.

“It is embarrassing to reveal, but it is a fact that NACP staff has not received salaries for the last 10 months because funds could not be released. There is political will to eradicate polio, but, unfortunately there is none to prevent and treat HIV. Although HIV is a bigger health catastrophe compared to polio in this country. If at any time GF stops funding this programme, within a few weeks, we will not have a single tablet for HIV patients,” he explains.

Additional reporting by Ashfaque Yusufzai in Peshawar and M B Kalhoro in Larkana.

Silent death

Drug users with HIV in Pakistan are left to fall by the wayside

By: Faiza Ilyas

Suffering multiple relapses after undergoing expensive therapies for drug addiction at Karachi’s private healthcare facilities, Sohail travelled for treatment to an antiretroviral therapy (ART) adherence unit in Islamabad.

The facility is administered by New Zindagi Trust (NZT) — a healthcare organisation working with communities affected by drug use and HIV/AIDS — and established with support from the Global Fund (GF).

Sohail was registered with Pakistan Society (PS) — a non-governmental organisation focused on drug rehabilitation in Karachi — that receives funding from NZT. The organisation liaised with NZT for his rehabilitation in Islamabad.

Injecting drug use is the main cause for the rise in HIV because of needle-sharing.— White Star
Injecting drug use is the main cause for the rise in HIV because of needle-sharing.— White Star

Last May, tragedy struck the family when they were informed of Sohail’s death, two days after he had left for Islamabad.

“My brother’s prolonged drug addiction followed by his HIV positive status constantly worried me at the time, but now I feel guilty for sending him to another city for treatment. Even after a year, I have not been told what caused his sudden death,” Faisal Ali tells Dawn.

Though his brother was physically weak, he was declared fit to travel by a doctor at NZT’s Malir centre in Karachi.

“Being a drug user, Sohail was worried about travelling without drugs. But staff at the NZT centre said there was no need to worry,” he says.

Sohail left for Islamabad with other patients in a NZT vehicle on a Saturday morning. On Monday afternoon, Faisal received a call that his brother had died.

“He was my only brother. The family was shocked and blamed me for his death, though I tried to pacify them by lying that he had died of heart failure. I received his dead body the next day in Sohrab Goth,” he says.

Sohail’s case is not an isolated incident. Sources informed Dawn that at least six patients have died over the past year alone, including three during treatment at the NZT adherence unit in Islamabad.

Moreover, the Bridge Consultants Foundation (BCF), another not-for-profit, has reported the death of two patients registered with them – both patients were HIV positive and drug users and died while travelling to an NZT facility in Islamabad.

As sub-recipients of GF grants, both PS and BCF implement the HIV/AIDS programme through the National AIDS Control Programme (NACP) and NZT.

Source: Integrated Biological & Behavioual Surveillance in Pakistan 2016-17.
Source: Integrated Biological & Behavioual Surveillance in Pakistan 2016-17.

Sohail, who developed serious withdrawal symptoms, reportedly died soon after he arrived at the adherence unit.

“We don’t know exactly how these patients died, since their death certificates received from NZT simply note that they were brought dead to PIMS Hospital in Islamabad,” says Ahzar Hussain, a programme manager at PS.

Although the organisation expressed its concerns in an email to NZT, GF, UNAIDS, the Sind AIDS Control Programme and NACP, they have yet to receive a response, he says.

The email dated May 15, 2016 was sent by Dr Saleem Azam, president of Pakistan Society to all the above mentioned, referring to the ‘inadequate’ transportation arrangements.

It reads: “Recently, on 15 May, 2016, a group of HIV +ve patients was on their way to AAU, Islamabad, accompanied by a CD4 technician. A patient namely Mr. SH, aged 34, stably healthy, registered by Pakistan Society, developed diarrhea and vomiting during the travel. No medical care was sought by seeing any medical professional on the way. The patient arrived AAU on the next day when he expired soon after his arrival.”

The email (a copy is available with Dawn) notes the absence of a doctor and paramedic required to assist patients when they travel.

“Two other patients, registered by Bridge [Bridge Consultants Foundation], were jettisoned on the way, such a happening not being an unusual occurrence.”

It suggests that a facility should be set up in Karachi to “save HIV positive patients, many of them habitual drug users who can experience brutal withdrawal symptoms, from a long travel of about 1,500 kilometers that usually takes more than 24 hours of continuous road travelling.”

According to Mr Hussain, PS operated a 50-bed detox centre for injecting drug users with NZT support for over a year in Karachi.

It was shut down in December 2015 when the trust informed them that patients would be referred to the ART unit in Islamabad.

This is why Dr Sharaf Ali Shah, heading BCF, insists that an ART unit in Karachi is essential for treating HIV-positive injecting drug users.

Injecting drug use is the main cause of the rise in HIV because of needle-sharing and insufficient prevention services.

About 37,137 inject drugs in Pakistan and 50pc have HIV.

In Karachi, 48pc of drug users are infected with HIV and adherence to treatment will only stop the spread of HIV to the general population.

When Salman-ul-Hasan Qureshi, the programme manager at NZT was asked whether a doctor accompanied patients to Islamabad, he admitted that none had travelled.

However, he insisted that there had never been a ‘major mishap;’ that reports of patients’ deaths were untrue.

When asked about the email sent by PS after the death of patients registered with them, Mr Qureshi said: “We talk directly to our partners and not through emails,” adding that, “No organisation is forced to work with us. If they have a problem with us, they can leave the partnership. Having said that, we agree that there should also be an ART unit in Karachi and we have submitted a proposal in this regard.”

Mr Tariq Zafar, the executive director of NZT says it has treated 2,700 HIV patients over the past three years at its Islamabad unit and less than 20 have died during this duration.

Treating HIV positive drug users

NZT started as a trust in 1989 with a 12-bed treatment centre in Lahore.

In 2011, the government asked them for support while treating HIV injecting drug users. Around 40,000 HIV patients have been registered by the trust.

Sharing details about the trust that works with communities affected by drug use and HIV/AIDS, Mr Qureshi explains it has been the principal recipient of GF funds since 2011-12, adding that the government’s share in funds was almost equal.

“We have worked extensively in Punjab and once partnered with the Punjab government as well. Presently, we are working in 30 districts countrywide, including three sites in Karachi, one in Khyber Pakhtunkhwa and two in Balochistan,” he explained.

Regarding services offered by NZT, he says, they include a syringe exchange service, counselling, HIV screening, drug treatment and rehabilitation, referral services and reaching out to street-based drug users.

All services are free of cost with GF support.

“The establishment of 200-bed ART unit in Barakahu in Islamabad is a success. Here, injecting drug users are provided detox therapy and they learn adherence to ART,” he adds.

Responding to why there is little focus on other high-risk groups, he says that injecting drug users are found to be the most vulnerable group to HIV globally — as is the case in Pakistan — and it is believed that if the disease was contained within this group, it would help prevent its spread to the general population.

Additional reporting by Ikram Junaidi in Islamabad

Nipping it in the bud

By: Mohammad Assai Ardakani and Mamadou L Sakho

Pakistan is experiencing a fast-moving HIV epidemic, with new cases showing an upward trend. Institutional deficiencies, societal stigma, and socio-economic complexities are few of the surmountable challenges that must be overcome to stop the spread of HIV.

That said, no other prevalent disease in Pakistan has the same widespread stigma attached to it as HIV. The resulting ostracising of sufferers can be partly attributed to the common but inaccurate notion that HIV occurs because of sexually deviant acts.

Contrary to this perception, there are multiple ways of contracting HIV, including sharing needle syringes. In the early to mid-2000s, Pakistan regressed from a high-risk and low-prevalence to a concentrated HIV epidemic among key populations.

However, given the present trend, it seems unlikely that the country will be able to achieve its goal of eradicating the disease by 2030 as pledged under the Sustainable Development Goals and the Political Declaration 2016 that has signatories promising to end AIDS as a public health threat.

The largest group of people living with HIV and AIDS are drug addicts because of needle-sharing and the unsafe injection of drugs.

Comprising an estimated 33 percent of the total population of HIV patients, this group continues to contribute the largest numbers of new infections annually.

This group is followed by men having sex with men, female sex workers, and the transgender population.

The transgender community has the highest prevalence rate at 7.1pc, with an even higher figure for transgender sex workers at 7.5pc.

According to a survey by the National AIDS Control Programme, using data from 23 HIV treatment centres, 21 community home-based centres, and 12 centres to prevent mother-to-child transmission, only 18,440 people are registered as HIV positive.

Furthermore, only 8,888 of these registered patients are receiving treatment, as of December 2016.

The coverage rate is even lower for people with HIV from key populations (drug users, etc.) at 4pc, even though they account for an estimated 61pc of those affected. This is a poor uptake with at least 133,299 living with the disease.

So, what prevents patients from registering for free treatment?

Factors include travel distance, limited opening hours for treatment centres, complex registration procedures, attitude of healthcare workers, and weak confidentiality protocols.

Many HIV positive persons hide their status fearing social backlash.

Given the lack of an accurate picture, the government has been unable to devise appropriate strategies for prevention and control.

Meanwhile, blame for the lack of prevention cannot be solely attributed to the health sector. Instead, several socio-economic factors contribute to lack of control making it imperative that HIV prevention and control is not simply perceived as a health issue but as a wider inter-sectoral challenge.

Poverty that fuels sex work and unsafe injections leaves HIV sufferers with fewer resources for treatment.

The transgender community is at greater risk with inadequate access to education and health that further increases their vulnerability.

Therefore, it is crucial to bring these key populations from the periphery into the mainstream.

Governance at the provincial level is another crucial factor affecting the HIV response.

After the devolution of power, the provincial AIDS control programmes are responsible for implementing the HIV response.

Both the Pakistan AIDS Strategy as well as provincial AIDS strategies have been recently revised with support from UNAIDS.

Despite the legal backing, there is a lot of variation in response to HIV from province to province.

For example, in a recent surveillance round, there was a stark difference in Punjab and Sindh.

In Punjab, where services for key populations exist, there was lesser HIV prevalence compared to Sindh where no services have been offered to key populations for almost three years.

The UNAIDS Fast-Track approach to ending the AIDS epidemic has a set of time-bound targets globally, including reducing the number of people newly infected with HIV from 2.1m in 2015 to fewer than 500,000 in 2020, reducing the number of people dying from AIDS-related illnesses from 1.1m in 2015 to fewer than 500,000 in 2020 and eliminating HIV-related discrimination.

It will be impossible to achieve UNAIDS Fast Track targets for Pakistan, if no catalytic action is taken, especially in the provinces.

An accelerated set of interventions tackling the spread of HIV and de-clunking the administrative processes is the need of the hour.

This is a collective responsibility and it is time that we acknowledge the gravity of the problem before it’s too late.

Mohammad Assai Ardakani is the country director for the World Health Organisation and Mamadou L. Sakho is country director at UNAIDS