Jamila Iqbal ( Department of Microbiology and National Health Research Complex, Lahore. )
N. Rehan ( Pakistan Medical Research Council, Shaikh Zayed Postgraduate Medical Institute, Lahore. )
Sero-prevalence of HIV was tested among 16,170 individuals. They included 215 patients with sexually transmitted diseases (STD), 77 I/V drug users, 21 commercial sex workers, 987 patients on haemodialysis, 119 subjects referred for HIV testing, 12,482 voluntary blood donors, 360 ante-natal attenders, 73 tuberculosis patients, 674 Pakistanis travelling abroad and 1162 persons who had received multiple blood transfusions. Ten persons were seropositive (0.06%). All of them came from the 119 subjects, suspected to be suffering from AIDS. The predominant mode of transmission was heterosexual (50%), blood transfusion (30%), homosexual (10%) and vertical (10%). All cases acquired infection outside the country. Comparisons have been made with other national studies (JPMA 46:255, 1996).
According to the official statistics of National AIDS Program of Pakistan, 1.35 million individuals have been screened for HIV till 31st March, 1995. Majority of them are blood donors and those falling in high risk categories. Out of them, 869 are MW positive and 51 full blown cases of AIDS, representing a seropositivity of 0.07%. Till the end of 1994, seven reports have been published on the prevalence of HI V/AIDS in the country1-7. Five of these reports have come from Karachi1-5, one from Peshawar6 and one from Rawalpindi7. The prevalence of MW is known to have regional differences8. The present study is the first report of a mixed population from Lahore.
Subjects and Methods
The study is based on the records of all those individuals, who were tested for HIV/A1DS at the Department of Microbiology, Shaikh Zayed Hospital, Lahore between 1987 and 1994. This department is a WHO focal point for AIDS. During the study period, 16,170 individuals were screened; 2,581 belonging to high risk and 13,589 to low risk categories. They included voluntary blood donors (12,482), patients who were multi transfused (1162), those on haemodialysis (987), travelling abroad (674), ante-natal attenders (360), STD patients (215), IJV drug users (77), TB patients (73), commercial sex workers (21) and 119 clinically suspected cases referred for HIV screening. Patients with SID, I/V drug users, commercial sex workers, those who received multitransfusions, those on haemodialysis and those clinically suspected to have HIV were grouped as “High Risk Category".
All tests performed were based on detection of HIV antibodies in serum samples. HIV-antibodies were demonstrated by commercially available kits. All samples collected during first five years of study (1987-91) were initially tested by ELISA (Welicozyme HIV). During this period, all reactive samples were sent to the referral centre of National AIDS Control Program at National Institute of Health for the confirmation by Western Blot Technique. Thus, first six cases diagnosed till 1991 were confirmed by Western Blot Technique. Samples tested during 1992 and onwards were initially screened by agglutination technique (Serodia - HIV). Positive sera were confirmed by two different ELISA Techniques (Abbott Recombinant HIV and weilcozyme HIV) as recommended by WHO.
Out of 16,170 individuals screened, only 10 were positive for HIV on Western Blots ELISA, representing a sero positivity of 0.06%. The sero positivity was 0.38% among 2,581 high risk individuals and nil among 13,589 low risk individuals. H[V positivity among various categories of individuals is shown in Table I.
The positive cases were found only among those individuals, who were clinically suspected to be suffering from AIDS. None of STD patients, IN drug users, commercial sex workers, patients on haemodialysis or those with history of multiple transfusions tested positive for HIV One positive case was a foreign national from Ghana, while the rest were Pakistanis and one had dual nationality.
Table II describes the socio-demographic characteristics, mode of transmission and the present status of 10 positive cases. The most common mode of transmission was heterosexual (50%) followed by blood transfusion (30%), homosexual (10%) and vertical transmission (10%). In all cases, except one with vertical transmission, infection was acquired outside the country, mostly in Middle East. The person at S.No.7 was the father of child at S.No. 8. (Table III).
A detailed scrutiny of their history revealed that his wife got multiple transfusions during their stay in UAE. She became sero positive and the husband acquired the disease from her and the daughter was vertically infected.
The sero positivity rate in our study (0.06%) agrees closely with the national statistics about HIV positivity (0.07%). A comparison with our major studies is shown in Table III. Although no national survey of AIDS has so for been undertaken, yet many regional studies are available1-7. The maximum data has emerged from Karachi Metropolis. According to a latest report published in 1994, Kayani et al1 screened 47,609 individuals and found a positivity rate of 0.07% by Western Blot. They were not able to find any indigenous case of AIDS. The largest group of positive patients was represented by foreigners/expatriates, individuals with frequent travel history and recipients of multiple transfusions. The common denominator in all these cases is the fact that HIV infection was acquired outside Pakistan by different modes during their long or short stay abroad. Two other large series were reported from Peshawar and Rawalpindi2,3. In a cross-sectional study, Raziq et al6 screened 34,353 individuals in Peshawar. These included blood donors, recipients of multiple transfusions, STD patients, tuberculous patients, pregnant women and Pakistanis coming fromabroad. Among them, 35 persons were HIV positive (0.1%). The mode of transmission in 31 was heterosexual and in 2 homosexual, in one through blood transfusion abroad and in another through I/V drug abuse. Thirty- three of them (94.3%) got the infection from abroad and the remaining two females (5.7%) acquired it from their husbands. Another major study by Tariq et al7 ‘from Armed Forces institute of Pathology, Rawalpindi, deals with 54,170 individuals screened since 1989. These included 48,235 blood donors, 3,369 persons proceeding abroad, 561 patients of venereal diseases, 350 lymphoma cases, 21 deportees from the UAE, 460 clinically suspect and cases of AIDS, 735 persons who were worried that they may not have HIV infection and 439 family members of HIV positive cases. Out of them, 30 persons (0.05%) were found positive for HIV. Of these 30, only three acquired the disease in Pakistan, 20 had acquired HIV infection during their stayin the Gulf States one in Saudi Arabia, one in Greece, two in France, while three cases bad it from South East Asia.
A study by Mujeeb and Hafeez4 conducted at Karachi in 1993, revealed HIV positivity of0.29% among 2776 individuals. Sero positivity was 0.95% among 844 subjects in high risk group, whereas, they did notfindany HIV positive casearnong 1932 low risk individuals. An earlier study by Mujeeb and Hashmi3 conducted in 1988 found that among 1363 blood donors, only 2 cases were HIV positive (0.15%). Both were married females aged 30 and 45 years who gave a history of obtaining multiple transfusions. In another study Mujeeb and his associates4 studied 1655 blood donors during 1991. There was no positive case of HIV amongst this population.
Khanani et al5 reported 3 confirmed cases of HIV infection in a group of413 screened individuals from Karachi in 1990. Two were foreign nationals of Tanzania and Uganda and third individual was a Pakistani national residing in Saudi Arabia, who had received multiple transfusions following a car accident in 1981.
A review of various studies reveals that heterosexual transmission is the commonest mode of transmssion. Out of 35 sero positive cases reported by Raziq et al6, 88.6% and in the series of Tariq et al7. 56.6% cases were heterosexual. In our study also, the most common mode of transmission among; HIV positive cases, was heterosexual transmission. Commercial sex workers have been blamed as a potent source of AIDS. In Pakistan, there has been no study of sufficient size in commercial sex workers. According to a survey conducted by National AIDS Program between October and December, 1993, out of 594 female commercial sex workers of Lahore, eight tested positive for HIV representing 1.3% positivity rate (Personal Communication). data so far available shows that although the situation is n grave, yet an epidemic is knocking on the door. Policy maker social scientists and preventive health specialists owe to the nation a clearly defined, scientifically sound and culturally appropriate policy to combat this menace.
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