- HIV/AIDS in Pakistan
HIV is not currently a dominant epidemic in
Pakistan. However, the number of cases is growing. Low awareness of HIV/AIDS in Pakistan, very high drug use and lack of acceptance of non-marital sex in the society have allowed the AIDS epidemic to take hold in Pakistan. AIDS may yet become a major health issue. [ [http://www.paktribune.com/news/index.shtml?156327 Pakistan sitting on a ticking AIDS bomb] By Amir Latif]
The National AIDS Programme’s latest figures show that over 4,000 HIV cases have so far been reported since 1986, but UN and government estimates put the number of HIV/AIDS cases around 80,000 ranging from lowest estimate 46,000 to highest estimate-210,000 [ [http://www.aids.gov.br/data/documents/storedDocuments/%7BB8EF5DAF-23AE-4891-AD36-1903553A3174%7D/%7BFD4B5F2E-FB97-4749-BDA2-1C2360F59870%7D/2007_epiupdate_en.pdf UNAIDS Epidemic update 2007] ] . Over all prevalence of HIV infection in adults aged 15 to 49 is 0.1%. [ [http://www.nacp.gov.pk/wp-content/uploads/2008/02/pakistan_2008_country_progress_report_en.pdf Pakistan UNGASS Report 2007] ] . Officials say that the majority of cases go unreported due to social taboos about sex and victims’ fears of discrimination [ [http://www.paktribune.com/news/index.shtml?156327 ibid] ] . On the other hand, more detailed and recent data suggest that this may be an overestimate [ [http://www.thelancet.com/journals/laninf/article/S1473-3099(08)70054-9/fulltext New government in Pakistan faces old challenges] ] .
Evolving phases of HIV epidemic
HIV epidemic evolves in three phases. First phase is low prevalence, when prevalence of the disease is less than 5% in any high risk group of the country. Second phase is concentrated epidemic when proportion of infected people in any high risk group rises more than 5%. Third and last phase of epidemic is generalized epidemic when prevalence of HIV infection rises over 1% among blood donor or pregnant women. Current data suggest that Pakistan has a concentrated epidemic among injection drug users in most cities and among male sex workers in a few cities.
Pakistan- The Escalating Epidemic
Pakistan enjoyed a low prevalence phase of epidemic from 1987 to 2003. This may have been due to lack of formal surveillance systems, althugh no study found significant HIV in any group until 2002. In 2003, an outbreak of HIV among injection drug users in one city heralded the onset of HIV epidemic in the country. Since then different studies and the national HIV surveillance (which started in 2004) have confirmed an escalating epidemic among IDUs and more recently among male and transgender sex workers. Currently the national average prevalence of HIV among IDUs is nearly 20%. Several cities also show concentrated epidemic among MSWs/ TSWs as well [ [http://www.nacp.gov.pk/wp-content/uploads/2008/01/r-2-report.pdf HIV/AIDS Surveillane Project, National AIDS Control Program, Minsitry of Health 2007] ] .
Other groups that also have HIV among them are truck drivers, expatriated migrant wokers and wives of IDUs. Two studies of men from the general population: Faisel and Cleland [ [http://sti.bmj.com/cgi/content/abstract/82/4/307 Migrant Men: A Priority for Pakistan: Faisel and Cleland, STI 2006] ] and A Study of Bridging Populations (The Population Council/ NACP 2007 [ [http://www.popcouncil.org/pdfs/Pak_STIsStudyReport.pdf] ] ) show no HIV and few STIs in this group. Similarly a study of women attending labor and delivery clinics in 4 cities had shown no HIV and rare STIs (NACP 2001) [ [http://www.nacp.gov.pk/wp-content/uploads/2007/04/summary-sti-prevalence-study-in-pakistan-2000.pdf The STI Prevalence Study 2001] ] . Furthermore blood donor screening data all over the country are suggesting low HIV infection in the blood donor population, albeit with some increasing trends in selected centers.
A number of factors may have contributed to keeping the overall transmission of HIV within the general population. One, Pakistan is a predominantly Muslim country with near universal circumcision. Secondly, taboos on sex may have led to a higher proportion of the need for non-marital sex to be met via sex between men, much from a smaller group of men within each person's acquaintance. Some of this is suggested by the fact that about 45% of all sex acts sold are by either male or transgender sex workers (HIV/AIDS Surveillnce Project 2007). These factors may have led to a high rate of HIV transmission among MSM/MSW networks but may (temporarily) slow down the transmission of HIV to the rest of the population.
However, a major factor that must be accounted for in the overall HIV transmission scenario is the rampant use of theraputic injectons, often with non-sterile injection equipment. With an average of about 9 such injection per capita annually (Janjua et al, Pasha et al), this may potentially be the major route via which the infection may reach the general population from IDUs.
National Response to HIV epidemic
Pakistan’s response to HIV/AIDS began in 1987 with the establishment of a Federal Committee on AIDS by the Ministry of Health. The national AIDS control Program was then established. It is objectives are the prevention of HIV transmission, safe blood transfusions, reduced STI transmission, establishment of surveillance, training of health staff, research and behavioral studies, and development of program management.
The prevention efforts received a major boost since 2004 when a World Bank loan/ grant allowed the Ministry of Health (and the provincial Departments of Health) to start a program which seeks to provide HIV prevention services to IDUs, sex workers and truckers; perform advocacy and communication for the general public and covers significant proportin of the national blood supply for HIV, HBV and HCV screening. This "Enhanced HIV/AIDS Control Program" has been able to establish these services using NGOs to perform the interventions in most large cities although the quality of the services as well as the completeness of their "coverage" remains low. Overall the IDU programs in Punjab are performing the best with over 70% coverage of target populations with services in4 cities. Programs for sex workers lag somewhat but are bolstered by the fact that the metropolises had higher levels of knowledge and safer behaviors. However, the overall levels of coverage of services remain low at around 16% for IDUs and <10% for sex workers nationwide. The communication project has performed probably the least with only 44% of Pakistani women reporting ever hearing of the word "AIDS" in 2007 [Ahmad FA and Khan AA. Knowledge of HIV/AIDS and Other Sexually Transmitted Infections; Pakistan Demographic and Health Survey: Chapter 13. Page 155 (2006 - 2007)] . Finally HIV treatment was started in 2005. Currently over 600 individuals receive free HIV medicines and tests from 9 public and private sector facilities.
Going forward the Government of Pakistan is in the process of approving a new ambitious 5 year plan that will be worth over $130 million. A number of challenges will have to be met during this phase. Foremost perhaps will be developing the methodology of measuring the impact of program interventions. A National M&E Framework has been developed but implementation on it has yet to start. Other challenges that will need to be overcome include establishment of a transparent financial management and a smooth logistical and procurement system.
* [http://www.nacp.gov.pk The official site of the National AIDS Program of Pakistan]
* [http://www.aidsportal.org/overlay_details.aspx?nex=82 AIDSPortal Pakistan page] Latest research, case studies and news stories
* [http://www.usaid.gov/our_work/global_health/aids/Countries/ane/pakistan.html USAID Pakistan]
* [http://lnweb18.worldbank.org/sar/sa.nsf/Countries/Pakistan/404E98A008CCD10F85256DC500278B4A?OpenDocument Pakistan HIV/AIDS Brief]
* [http://www.youandaids.org/Asia%20Pacific%20at%20a%20Glance/Pakistan/index.asp HIV and AIDS in Pakistan,HIV in Pakistan,AIDS in Pakistan ...]
* [http://www.worldbank.org.pk/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/PAKISTANEXTN/0,,contentMDK:20154303~pagePK:141137~piPK:217854~theSitePK:293052,00.html Preventing HIV/AIDS in Pakistan]
* [http://sapnamagazine.com/Winter06/articles/culture/w06-aidsinindia.html Aids Crisis in India] Sapna Magazine Article
* [http://www.aids.gov.br/data/documents/storedDocuments/%7BB8EF5DAF-23AE-4891-AD36-1903553A3174%7D/%7BFD4B5F2E-FB97-4749-BDA2-1C2360F59870%7D/2007_epiupdate_en.pdf UNAIDS Epidemic update 2007]
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