PAKISTAN is slowly advancing towards a public health nightmare with a national survey showing that almost 135,000 people could have contracted HIV/AIDS infection. The country is one of 10 nations that account for 95 per cent of all new cases of HIV infections globally. Although the figure for those with HIV/AIDS might appear to be nominal given Pakistan’s total population, the fact that cases are reported to have gone up by approximately 40,000 from last year is extremely alarming.

The situation is also worrisome because the country is facing a “concentrated [HIV] epidemic among injecting drug users” (IDUs). According to the Asian Epidemic Modelling conducted in 2015, the primary mode of HIV transmission in Pakistan continues to be the use of contaminated injection equipment among people who inject drugs (PWID).

Pakistan sits at the so-called golden crescent of the illicit drug trade. It is situated next door to Iran and Afghanistan, with the latter being the world’s largest producer of opium and provider of 85pc of the world’s heroin.  Pakistan is thus a lucrative transit zone for illicit drug trafficking, and at least 20 tonnes of pure Afghan opium is consumed in Pakistan every year, according to the United Nations Office on Drugs and Crime (UNODC). In 2012, HIV prevalence among IDUs in major urban centres in the country was close to 21pc. By 2015, it had gone up to 40pc in several cities, including Karachi, which is at the nexus of global drug trade routes and is one of the world’s top cities registering a rise in HIV prevalence.

Pakistan needs to implement programmes in prisons to control an expanding HIV epidemic among IDUs.

The situation is worsened by the fact that populations most at risk of contracting the infection are given the lowest priority by government and policymakers. A prime example is of prison inmates, who have a high prevalence of HIV due to the overrepresentation of PWIDs among them. An estimated 40pc of Pakistan’s prison population uses drugs. The prevalence of HIV is worse among drug-dependent inmates because their environment is conducive to high-risk behaviour, particularly needle-sharing and unprotected sexual activity.

A situation assessment of IDUs in four cities in Punjab revealed that 80pc of PWIDs had been to jail. Among these former inmates, 56pc had used drugs in prison, of which up to 70pc had done so via injection. Another study, conducted on 5,000 prisoners in Lahore’s district and central jails, put the overall HIV prevalence at 2pc. Unfortunately, the situation is not unique to Punjab and might be worse in Sindh, particularly in Karachi. A 2010 study that focused on male prisoners in Karachi revealed that among 357 randomly selected inmates, 2pc were HIV positive, 5.9pc were infected with Hepatitis B while 15.2pc had Hepatitis C infection; 59.2pc of the sample self-reported as using illicit drugs while 11.8pc of those reported injecting drugs.

Another study in 2012 on a sample of 1,198 prisoners recorded positive responses from 15pc and 16pc of respondents for having used opium and heroin respectively at some point in their lives while 32.9pc and 50.9pc of them reported having used drugs in prison. Finally, 12.3pc reported injecting drugs in prisons. These are conservative figures due to the likelihood of underreporting especially in a prison setting.

Disease testing in prisons has been sporadic and conducted on a small scale. The severity of the problem has thus likely been underestimated and support initiatives are non-existent. Current programmes outlined in the Drug Control Master Plan 2010-2014 focus on demand reduction strategies, including community mobilisation and rehabilitation facilities. However, there is no focus on harm reduction, shown to produce favourable results in a wide range of prison settings globally.

Pakistan has been using needle and syringe programmes since 2003-2004 but none of the programmes are operational in prisons. In fact, drug-use related arrests have hampered the scaling up of existing NSPs. The spread of HIV in prisons is a public health nightmare as many prisoners return to their communities and the disease can multiply.

Many countries including Iran have experimented with harm-reduction programmes in prisons such as Prison-based Syringe and Needle Programmes (PSNPs) as well as Opioid Substitution Therapy including Methadone Maintenance Treatment (MMT). These programmes have been shown to reduce needle-sharing and blood-borne infections among at-risk prison populations. 

After Iran made harm reduction official policy in 2005, the rate of HIV infections in the country, which had thus far been on the rise, began to decline steadily. By 2008, only 18pc of injecting drug users were HIV positive; the figure was estimated to have been 40pc in the absence of such programmes. Pakistan needs to implement simple and confidential harm-reduction programmes in prisons as a matter of urgency to control an expanding HIV epidemic among IDUs.

In 2006, the UNODC, WHO, and UNAIDS jointly published recommendations for the provision of clean injection equipment during detention and on release of prisoners as part of their effective national response to HIV/AIDS in prison. Evidence from PSNPs suggests they are readily accepted by IDUs and over time, lead to a reduction in needle-sharing.

Iran’s PSNP, introduced to 347 volunteer prisoners, brought down the weekly use of syringes for intravenous drug injection from 17 to zero.  Current evidence also dismisses concerns regarding increased drug use or injecting in prisons as no negative unintended consequences have been reported.  Similarly, the availability of MMT has demonstrated notable improvement in the physical and psychological health of the recipients.

The success of Iran’s prison-based harm reduction programme is an important reference point for Pakistan. Drugs are considered taboo in both societies, not only as a social evil but also as being contrary to religious precepts. Nevertheless, Iran has experimented with harm reduction and although it has faced difficulties in implementation and is still working on finding the perfect model, assessments have shown promising results.

If harm reduction can prove beneficial in a much more conservative setting as Iran, it is time Pakistani policymakers looked beyond conventional programmes and experimented with bold and innovative solutions.

The writer has research interests in security policy, trafficking and public health. She has worked with Unicef in Tajikistan on HIV positive children.

Published in Dawn, November 6th, 2017