Male visitors get necessary information about HIV from a volunteer at the screening camp.
Over a dozen parents interviewed by Eos, at various health facilities and the screening camp at THQ Hospital Ratodero, said they never took their children to the accused doctor. The interviews were also corroborated by health care providers at the screening camps.
“Since the outbreak, I have seen women walk in more frequently at the hospital. Earlier, it would be a woman every few months but, in the past 10 days, I have seen eight cases. One woman each is from Shikarpur and Dadu while the remaining cases are from Ratodero,” says Dr Isran.
Urging for more screenings and awareness, Dr Isran says a lot of work needs to be done to raise awareness to save women and thereby their babies from HIV.
What Went Wrong?
According to the UNAIDS 2017 factsheet, Pakistan is home to an estimated 150,000 HIV-positive people, with some 3,500 under the age of 14 years. 22,000 Pakistanis living with HIV know of their status while only 12,000 are currently on antiretroviral therapy (ART). The national and provincial AIDS control programmes say the actual numbers of people with HIV is likely much higher.
Since the first reported case of HIV in 1987 in the country, the epidemic took root mainly in high-risk populations — drug users and sex workers — as well as migrant workers in the Gulf deported back to Pakistan once their HIV-positive status was known. A poor health care system, and social stigma made talking about HIV a taboo, however.
The HIV epidemic in Larkana district is also not a new one. The first HIV case was reported there in 1995. Eight years later, in 2003, the city garnered attention when the first outbreak of HIV among injecting drug users (IDUs) was reported. Out of 175 IDUs, 17 were confirmed positive. A paper titled “Alarming Increase in Reported HIV cases from Larkana, Pakistan: A Matter of Serious Concern,” published in the Journal of the Pakistan Medical Association in 2014, notes:
“In 2008, results of … national surveillance suggested 27.6% hijra [sic] sex workers were confirmed HIV positive. This [Larkana] has to be a unique town in Pakistan because of an unusual pattern of multiple commercial sex activities happening here. It has a functioning brothel where clients from all over the district as well as from the other cities visit female sex workers in [the] daytime for commercial sex. Additionally, there are home-based sex workers as well, who [see] clients on [a] regular basis. There are at least two musafirkhanas [motels] on Station Road in the middle of the city where hijra [sic] and male sex workers are available round the clock to provide paid sex services to clients.”
The report goes on to add that the city has all the ingredients of an exploding HIV epidemic in the near or distant future.
That prediction came true in 2016 when a hemodialysis-unit-related outbreak in Larkana made headlines and the number of HIV-positive people in the district crossed the 1,200 mark. With HIV present in a high-risk population — comprising of IDUs, female sex workers, transgender sex workers and men who have sex with men — for around two decades, and with unregulated blood banks, the rampant reuse of unsterile syringes, rudimentary healthcare facilities, poor infection control practices and untrained healthcare workers, the infection finally made its way to the general public.
“HIV/AIDS was never considered an emergency or a big issue,” says Dr Sikandar Memon, programme manager of the SACP. “This is a very small programme going nowhere. When there are so many unsafe practices all over the country, anywhere you test you will end up getting some HIV-positive people.”
He says that, despite funding crunches, the SACP has been working diligently with high-risk groups. “But we don’t have enough resources or the mobilisation capacity to reach the general public.”
So how high is the provincial AIDS control programme on the list of the Sindh government’s priorities?
In terms of response, it took the Sindh Health Minister Dr Azra Pechuho 20 days to visit the screening camp at Ratodero. In a press conference later that day, she said it wouldn’t have made much of a difference had she visited earlier.
According to sources, the PC-1 budgetary allocation for SACP was earmarked at Rs1,623m for a period of three years (2016-19). The budget was released in 2017 and so far only Rs211m has been disbursed. Then, when the programme made a request for Rs38 million for RDT kits for the ongoing fiscal year it received only Rs4.9m. Since the outbreak, an additional 22.6m rupees have been released. The SACP’s service delivery programme has not been functional since 2014. Only when funds are available are the NGOs and community-based organisations engaged for awareness campaigns.
The SACP has seen its fair share of controversy, too. In July 2018, the executive board of the National Accountability Bureau approved an inquiry against SACP Programme Manager Dr Muhammad Younas Chachar and others for misuse of authority and embezzlement in government funds that allegedly caused a loss of Rs35.236 million to the national exchequer. Chachar retired on January 19, 2019.
Dr Memon became the SACP programme manager on February 6, 2019, after being sidelined as an OSD (Officer on Special Duty) in the provincial health department. Nevertheless, the ongoing screening effort currently underway in Ratodero saw him actively lead his team, along with other stakeholders — a task which is beyond the scope and resources of the SACP.
Under its current strategy, the SACP has taken on board a team of infectious diseases specialists and experts from UNAIDS and the WHO to chalk out a short-term and long-term plan to deal with the HIV outbreak.
Dr Memon urges the government to ensure that the relevant departments work together to deal with this hydra-headed monster. He points out a dire need for collaborative effort. “We have to ensure decentralisation of treatments and testing services, setting up of satellite centres and existing network of public blood banks,” he says. “Strong referral mechanisms between the institutes are needed. Last but not the least, confidentiality of results has to be ensured.”
The Sindh Health Care Commission was established under the Sindh Government Act 2013 for regulating health care services in the province of Sindh. However, the commission obviously failed in keeping a check on healthcare facilities in the province and a tab on quacks. As a knee-jerk reaction after the HIV outbreak garnered news headlines, it had 41 clinics sealed in Larkana and issued notices to 100 medical practitioners for questionable practices.
Under its new head, Dr Durenaz Jamal, the Sindh Blood Transfusion Authority (SBTA) has also sealed some facilities. Furthermore, according to the SBTA, no bloodbank in Ratodero was registered with the authority. “These were small labs that were selling blood to the people without proper screening. There is no awareness amongst the people about safe blood and these labs were exploitative. This amounts to quackery,” says Dr Jamal. She adds that the SBTA always encourages establishing new blood banks, but only those which work according to its criteria and operating procedures.
Stepping up efforts