KARACHI: Infectious diseases experts say that while a clinical investigation needs to be carried out to assess the HIV ‘outbreak’ in Ratodero, Larkana district, the Sindh government must ensure availability of safe blood, sterile syringes, proper medical waste disposal mechanism and respecting the privacy of all individuals, including the accused doctor.

The news of 282 children and adults (as of May 9) allegedly infected by an HIV+ doctor in Larkana made the headlines. The news of so many cases in a small town saw an almost sensational end when the doctor was arrested and put behind bars. Currently a joint investigation team is probing the matter.

The human immunodeficiency virus (HIV) can lead to acquired immunodeficiency syndrome (AIDS) if not treated. According to the Pakistan Economic Survey 2017-18, “Till date 4,500 HIV positive cases have been reported to the AIDS Control Programmes at federal and provincial level” — a phrase repeated in the survey reports since 2012-13. Meanwhile, the UNAIDS 2017 fact sheet estimates 150,000 adults and children living with HIV in Pakistan.

Dawn reached out to infectious diseases experts to find out the reasons behind the latest HIV outbreak in Larkana, whether a person with HIV (or Hepatitis B/C) could work in hospital settings (and just about anywhere else) and what measures are needed immediately to curtail further spread of the disease.

Ask Sindh government to ensure availability of safe blood, sterile syringes and proper medical waste disposal mechanism

“The HIV epidemic has been brewing for more than a decade. The condition has remained unrecognised because no one thought of looking into it,” says Dr Bushra Jamil, president of the Medical Microbiologists and Infectious Disease Society of Pakistan and head of Infectious Diseases at Aga Khan University. She notes that the HIV ‘outbreak’ surfaces from time to time when observant physicians recognised something not conforming to the usual pattern of common conditions.

For the uninitiated, an explainer on WebMD says a disease ‘outbreak happens when a disease occurs in greater numbers than expected in a community or region or during a season’, and defines an ‘epidemic as one which occurs when an infectious disease spreads rapidly to many people’ while ‘a pandemic is a global disease outbreak’.

“HIV is probably endemic in Larkana and adjacent areas. Cases get diagnosed only when someone decides to order a screening test. Since this (screening) happens sporadically, it gives a false impression of an outbreak,” says Dr Jamil.

“This is how the 2016 hemodialysis-unit-related outbreak of Larkana was identified with HIV being present in high-risk population for around two decades, unregulated blood banks which provide blood without screening and rampant reuse of unsterile syringes, rudimentary healthcare facilities and untrained healthcare workers. There is dire need to create awareness about not giving unnecessary injections (unless lifesaving) to infants and children, maintaining strict safety and hygiene protocols and availability of screened blood for transfusions,” she stresses.

Safe to practice?

When asked if an HIV positive doctor can practice, Dr Jamil says, “It’s fine. HIV positive doctors receiving treatment can practice and also undertake medical procedures, excluding certain complicated surgeries.”

A similar opinion was shared by Assistant Professor at Infectious Diseases, SIUT, Dr Sunil Dodai who called for de-stigmatisation of the diseases and said HIV+ healthcare providers could work in hospital and clinical settings.

The Centre for Disease Control (CDC) in Atlanta, United States, has estimated that the average risk of sporadic HIV transmission from an HIV-infected surgeon to a patient during an invasive procedure was 2.4 to 24 episodes of transmission per one million procedures. It further adds that HIV transmission from (asymptomatic) healthcare workers to patients using standard antiseptic technique is quite unlikely. The CDC notes that though HIV transmission is possible in healthcare settings, it is extremely rare.

Dr Dodai stresses the need for cutting down the use of injections and improving hygiene protocols at all medical facilities, including private clinics. He is of the opinion that the media must respect the privacy of all individuals who have tested positive.

Dr Dodai is part of a three-member technical team (led by Dr Shehla Baqi, with Dr Azizullah Khan Dhiloo as member) assisting the JIT investigating accused Dr Muzaffar Ghangro. The team has submitted its detailed investigation report.

While not disclosing the report’s conclusion till it is made public by the authorities, the JIT technical team members and other infectious disease experts say the current outbreak is ‘multifactorial’ (involving or dependent on a number of factors, especially genetic or environmental factors) and ‘making one man a scapegoat for this is unfair’. They also urged the media to report responsibly and stop demonising the doctor and the disease. The entire province is affected with such poor practices and micro-outbreaks have happened before, the doctors opined.

The infectious diseases specialists in their recommendation say the government must ensure that screened blood is available, and awareness is created about the usage of auto-lock syringes which can’t be reused. Furthermore, they stressed compliance by healthcare professionals, hospitals and blood banks with the required safety standards.

Privacy for the positives?

One of the biggest concerns shared by the medical community was that privacy of HIV+ individuals (including the doctor) was not respected in the recent reporting of HIV crisis. One healthcare provider noted that many of the men, women and children outed in the current and previous outbreak episodes were not in a position to give ‘informed consent’ and faced societal negativity.

Sindh AIDS Control Programme manager Dr Sikandar Memon says the media should refrain from sensationalising the news. “It would be great if an awareness campaign is launched to educate the masses and waiting for a consolidated report on the issue.” He stressed that provincial AIDS control programme respected the privacy of all positive individuals.

So what does the Constitution and law say about privacy of individuals? Article 14 of the Constitution guarantees the ‘dignity’ of man as a fundamental right. Under the Sindh HIV and AIDS Control Treatment and Protection Act, 2013, any person who publicises the confidential health information and/or records of another person in contravention to the provisions of this Act, shall be liable to imprisonment not exceeding five years and not less than two years and a fine of Rs200,000.

Health experts as well as many TV viewers agree that outing the identities of HIV+ individuals (particularly vulnerable women and children) serves no journalistic purpose.

Published in Dawn, May 11th, 2019