KARACHI: ‘Concentrated epidemic’ of HIV (human immunodeficiency virus) infection has been found in 22 of the 23 recently surveyed cities, with Karachi having the second highest number of injecting drug users living with HIV after Kasur, it emerged on Sunday.

According to experts, a concentrated epidemic is one in which HIV or any other infection has spread in one or more defined subpopulation (with prevalence consistently over 5pc in one or more high risk groups) but it is not well established in the general population.

Pakistan’s HIV epidemic, they say, has shifted from a low-prevalence state to concentrated state among the key populations at risk. This is derived from the fact that HIV prevalence in vulnerable groups has been found to be more than 5pc while its prevalence in the general population is less than one percent.

The four high-risk groups for HIV epidemic identified during the recent survey were: people who inject drugs, transgender, men who have sex with men (that includes both professional sex workers and those who indulge in the practice as a matter of preference) and female sex workers.

Previously when a surveillance was carried out in 2011, HIV epidemic was found limited to the first two groups. However, HIV epidemic was reported this time in all the four groups involving around two dozen cities.

Titled Integrated Biological and Behavioural Surveillance (IBBS) in Pakistan 2016-17, the report carries country-wide HIV surveillance data collected every five years. The study was jointly carried out by the provincial AIDS control progammes, National AIDS Control Programme (NACP), UNAIDS and Global Fund through commissioning of international expertise provided by the Global Public Health, University of Manitoba, Canada.

The field implementation partner NGOs were: Bridge Consultants Foundation (BCF), Karachi and Bahria University, Islamabad.

The cities/towns included in the survey were: Karachi, Quetta, Lahore, Rawalpindi, Peshawar, Bahawalpur, Turbat, Bannu, Dera Ghazi Khan, Faisalabad, Gujranwala, Gujrat, Jhelum, Kasoor, Multan, Sargodha, Sheikhupura, Sialkot, Hyderabad, Larkana, Mirpurkhas, Nawabshah and Sukkur.

The report shows that not only has the overall HIV prevalence increased, but the number of sites with relatively advanced epidemics has also expanded.

High-risk groups

Injecting drug users, according to the report, was one group identified with HIV epidemic in 14 cities. “The highest HIV prevalence in this high-risk group was found from Kasur (50.8pc), Karachi (48.7pc), Bahawalpur (25.1pc) and Mirpurkhas (23.2pc). Other cities which reported HIV epidemic in this group are Rawalpindi, Jhelum, Hyderabad, Sukkur, Larkana, Nawabshah, Peshawar, Quetta and Turbat,” the report says.

The highest prevalence for HIV among transgender was reported in Larkana (18.2pc), followed by Bannu (15pc) and Karachi (12.9pc). Ten cities reported concentrated epidemic among all transgender.

HIV epidemic among men having sex with men was reported from seven cities with Kasur (9.7pc) having the highest prevalence followed by Karachi (9.2pc), Nawabshah (7.5pc), Sheikhupura (7.4pc), Hyderabad (5.7), Gujrat (5.4pc) and Sukkur (5.1pc).

The rate of HIV prevalence among male sex workers was 5.6pc.

Sukkur had the highest HIV prevalence (8.8pc) in female sex workers, followed by Larkana and Mirpurkhas (4.1pc each), Nawabshah (3.8pc) and Peshawar (3.0pc).

“Pakistan needs to act fast, scale-up services for high-risk groups to contain HIV epidemic at its present level before it spreads to other vulnerable groups and into general population,” said Dr Sharaf Ali Shah, former director of Sindh AIDS Control Programme, who currently heads the BCF.

He said a multi-sectoral approach to achieve the 90-90-90 treatment for all target. “The government should take full advantage of this study by focusing on high-risk groups and start implementing the 90-90-90 strategy set by UNAIDS.

“This means by year 2020, 90pc of all people living with HIV will know their HIV status, 90pc of all people diagnosed with HIV infection will receive sustained antiretroviral therapy and 90pc of all people receiving antiretroviral therapy will have viral suppression.”

Dr Shah believed that the target was achievable if dedicated efforts were made to spread awareness about the infection and to enhance the level of HIV testing in vulnerable groups.

“Besides, Pakistan is getting free of cost HIV medicines though Global Funds. The drugs help a person live a normal life by stopping disease progression and preventing onward transmission of infection,” he explained.

Risky behaviour

The report provides important biological and behavioural information related to HIV infection prevailing among high-risk groups, which this year included separate categories for homosexual men (not professional sex workers) and male sex workers.

Transgender group was divided into two categories — transgender sex workers and transgender non-sex workers.

Of the total 4,062 injecting drug users interviewed, most were men and about half were married, 40pc illiterate and 62pc lived at home. The average number of injections per day ranged from 1.2 to 3.1 injections per day with Karachi and Bahawalpur reporting the highest number of injections per day (average 3.1 and 3.0, respectively). Peshawar reported the lowest number.

Poly drug use (use of two or more psychoactive drugs in combination to achieve a particular effect) was reported from nearly all cities. Heroin and injection containing antihistamine pheneramine maleate were the drugs of choice in most cities.

Around 31pc of injecting drug users reported sharing syringe/needle with other addicts at their last injection.

Syringe sharing

Sharing needle/syringe was most commonly reported from Bannu (65pc) followed by Nawabshah (60pc) and Kasur (56pc). About 40pc of injecting drug users had a regular female partner for six months. Condom use was low. More than half knew that HIV could be transmitted by sharp instruments/syringe while 52pc were aware of sexual mode of HIV transmission.

The youngest average age of initiation of drugs was reported in Bannu and Larkana at 23.3 years.

Overall HIV prevalence among IDUs was 38.4pc.

Most transgender surveyed were unmarried and complained against discrimination. A significant number reported use of alcohol/drugs during sex in past one year. Knowledge about HIV transmission mode was low.

Overall HIV prevalence among transgenders was 7.1pc; transgender sex workers 7.5pc and transgender non-sex worker 3.0pc.

Of the total 5,660 female sex workers interviewed, a large number (43.2pc) was illiterate, 47pc were married, most with children. A small number was widowed (3.4pc), separated or divorced (13pc).

Among the unmarried, majority worked at Kothikhana, followed by home-based workers. Use of condom was generally low. Overall 48pc of all female sex workers reported drinking alcohol and/or taking drugs over the past six months.

“Though HIV prevalence among female sex workers was the lowest among high-risk groups, there is concern over the higher prevalence (2.2pc) of HIV in this group during this round in comparison to the previous surveillance rounds,” the report says.

More than one third of all reported discrimination whereas about half of the female sex workers interviewed reported being tricked and/or lied into having sex and being beaten up and/or physically forced to have sex.

The overall HIV prevalence among male sex workers was 5.6pc and among men who have sex with men was 5.4pc.

Constant rise in HIV prevalence

“Although the estimated HIV burden of 0.1pc appears low and relatively stable, it masks the overall progress of HIV epidemic in Pakistan and doesn’t elucidate the deadly trajectory of the epidemic.

“Underneath a fairly steady and static HIV prevalence among general population, there is a proliferating epidemic which is continuously at a rise among key populations, which form the main agents in transmission and fuelling of the epidemic in the country,” warns the report carrying a list of recommendations.

Sindh, it says, suffers the most, where the epidemic was the noticed earlier and now sub-epidemics were seen in all key populations in most of the major cities investigated. But the sheer size of cities and key populations in Punjab doesn’t make the region less important. Data suggests that it is mere a question of time, and if left unchecked, Punjab will soon face similar or even larger sex-driven HIV epidemics.

“We know with increasing certainty what disaster awaits if the response to AIDS continues to be inadequate. We also know how to strengthen that response in ways that will save millions of lives and billions of dollars.

“This plan is achievable, but only with strong leadership at every level of society. We know what needs to be done to stop AIDS. What we need now is the will to get it done,” concludes the report.

Published in Dawn, July 17th, 2017