Larkana’s HIV outbreak

13 May 2019


The writer is an infectious disease specialist.
The writer is an infectious disease specialist.

FOR several years, bonfires were lighting up in small towns and villages of Sindh; bonfires turned to bushfires, and bushfires are now rapidly engulfing the forest. Brave firefighters are battling the conflagration. The fires typify the three lethal viruses: hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV), and occasionally, the bacterium that causes syphilis. All are capable of being transmitted through almost similar routes, ie sexual intercourse, blood, and from pregnant mother to child.

Until recently, Pakistan was rated as low burden (0.1 per cent) for HIV, but with recent recognition of the outbreak in Sindh, the statistics are likely to change to unpalatable numbers. Sadly, Pakistan also ranks highest in the world in hepatitis burden, with some areas reporting 25pc of the population infected with hepatitis viruses.

Pakistanis have a penchant for receiving injections and drips as a quick fix in lieu of healthy nutrition and lifestyles, encouraged and instigated by both licensed and unlicensed medical practitioners. The messengers of death feel no compunction in reusing virus-contaminated needles and syringes, razors, scalpels, dental equipment, or ear- or nose-piercing instruments. Even a miniscule drop of fresh or dried blood can transmit millions of virus particles; transfusion of a single unit of infected blood will inevitably hasten the disease attack.

Many lessons can be learned from this outrageous negligence of healthcare in Sindh.

For decades, Larkana has been a hotbed of intravenous drug users (IDUs), among whom an astounding 27pc are infected with HIV. Moreover, unlicensed and unsupervised blood banks in the city either do not screen donors’ blood or use substandard kits for testing, thus eluding the true state of infection. The deadly combination of IDUs and their blood donated to commercial blood banks is one of the bridges for the infection to transfer to the general population.

The recent spate of HIV cases emerged when it came to the attention of HIV-trained paediatricians that an unusually high number of children — whose mothers were uninfected — were being referred to their centres. This led to an uproar among infectious disease (ID) experts, who approached the chain of command at the National AIDS Control Programme in Islamabad, which is mandated by the Global Fund to provide diagnostics and treatment for HIV patients, funnelled through provincial programmes into centres established in high burden areas.

The Sindh AIDS Control Programme sprung into action and, through urgent meetings with local officials in Larkana and Ratodero, organised a joint investigation team in tandem with DG health Sindh, NACP, WHO, Unicef, People’s Public Health Initiative, Expanded Programme of Immunisation, Lady Health Workers, and clinical ID experts from the Medical Microbiology and Infectious Disease Society of Pakistan (MMIDSP) to investigate and control the epidemic. A short- and long-term strategy was rolled out to suggest and implement interventions.

Community leaders and media were engaged, and urged to do HIV reporting in a humane and empathetic manner. The media was advised to help destigmatise the disease and respect the privacy of victims by not sharing names, photographs and medical reports. The video of the affected doctor that was circulated on social media was declared as distasteful and against human rights, and the offenders were duly admonished.

The objectives of the JIT are to identify the epidemiologic factors for the outbreak (ie demographic and risk factors, suspected exposure and sexual behaviour) that would help to estimate the magnitude and determinants of HIV; to explore additional contacts and sites for its potential transmission; to determine the chain of transmission of infection; and to formulate appropriate and effective recommendations to interrupt itstransmission.

Blood screening of sections of high-risk population was carried out in Taluka Hospital, Ratodero. A preliminary report from the Sindh Directorate of Health Services survey screened 4,656 persons and identified HIV in 186 persons over only 12 days — a shocking 3.9pc. Of them, 108 (58.4pc) were male; children aged two to five years old were, sadly, highest at 102 (54.8pc). Treatment centres are in the offing; unauthorised laboratories, blood banks and clinics have been closed; and the public is receiving awareness sessions on disease prevention. Screening camps have been established, which will likely detect more hidden diseases in other towns and cities. This is only the tip of the proverbial iceberg.

Many lessons can be learned from this outrageous negligence of healthcare in Sindh.

First, awareness of cause is the best way of preventing any disease. Registered or unregistered healthcare workers should desist from giving injections and drips for profiteering, and patients should understand the serious consequences of receiving unnecessary jabs. Health authorities should have strict vigilance of blood screening in blood banks. People should be made aware of how engaging in unsafe sexual activities increases the risk of acquiring sexually transmitted infections.

Second, early diagnosis of any disease makes for better treatment outcomes. Stigmatisation, lack of confidentiality, and (as we have seen in several studies) missed diagnosis by inexperienced doctors makes for worse prognosis and outcomes. Medical curricula in most ‘boutique’ medical colleges do not incorporate the subject of ID that is so essential in Pakistan. Hence, HIV, its diagnosis, prevention and myriad associated complications are overlooked until the terminal stage of disease. The specialty of ID incorporates the largest spectrum of clinic diseases and infection control. The MMIDSP is a strong body that has played a pivotal role in managing the current outbreak; its members are ready, able and willing to help the government rewrite the ID curriculum and hold teaching sessions anywhere in the province to train physicians who have never received the benefit of didactic and practical training.

Finally, the onus is upon local municipalities all over Pakistan to improve sewage and solid waste management, which is the source of Pakistan’s health woes. We must stop firefighting. Rather, we must prevent fires. Our people deserve good healthcare, not disease and misery.

The writer is an infectious disease specialist.

Published in Dawn, May 13th, 2019