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January 2006, Volume 56, Issue 1

Editorial

HIV/AIDS in Pakistan

Yasmin Bhurgri  ( Departments of Pathology, Aga Khan University , Sindh Medical College , Karachi Cancer Registry ,Johns Hopkins University, Bloomberg School of Public Health, Baltimore,Maryland, USA. )

HIV/AIDS is no more a health problem; it has become a security issue as millions of people are at the verge of extinction. Around 90% of the AIDS victims are living in the developing countries where the incidence rate is aggravated by poverty, hunger, disease, lack of medical facilities, illiteracy and under-development.
Pakistan is an Islamic Republic in South-Central Asia, bordering the Arabian Sea (30 00 N, 70 00 E). It is situated between HIV/AIDS high risk countries, India on the east, China in the north, and Afghanistan on the west. Its only low risk neighbor is Iran. The estimated population of Pakistan is 162,419,946, with an annual population growth rate of 2.03% (July 2005). The population is young, the median age being 19.44 years in males and 19.74 years in females. The age structure is a typical developing country pyramid with the 0-14 years constituting 39.6% of the population (male 33,104,311/female 31,244,297); the 15-64 years group forming the bulk i.e. 56.3% (male 46,759,333/female 44,685,828) and the 65+ years comprising 4.1% (male 3,189,122/ female 3,437,055) of the population. Muslims comprise 97% of the population with the Christians, Hindus, and other religions comprising 3% of the population.1,2
Pakistan to a large extent has managed to remain relatively protected from the spread of AIDS to date. It is identified as a low-prevalence, high-risk country for the spread of HIV infection.3 By the end of 2000, a total of 1549 HIV positive and 202 AIDS cases had been reported; by December 2002 the number had risen to 1,998. In 2003, the Global Surveillance of HIV/AIDS and sexually transmitted infections (STIs), a joint effort of WHO and UNAIDS, worked closely with the Federal Government of Pakistan to calculate the HIV/AIDS burden of the country. The calculations were based on previously published estimates for 1999 and 2001 and recent trends in HIV/AIDS surveillance in the population. This group estimated HIV/AIDS positive adults aged 15-49 years in Pakistan to be 73,000, 8,900 being women. The general population prevalence was estimated as 0.1% and high-risk population prevalence as 1-2%. The male-to-female ratio was calculated as 42:6 and 7:1 (per 100,000) in reported HIV-positive and AIDS cases, respectively. The estimated AIDS deaths were cited as 4,900.3-12
The mode of HIV/AIDS transmission in Pakistan is largely heterosexual (52.55%), contaminated blood or blood products (11.73%) are the most commonly reported modes of transmission. Other modes of transmission include IDU - injecting drug use (2.02%), male-to-male or bisexual relations (4.55%), mother-to-child transmission (2.2%) and transmission of undetermined origin (26.9%). The cause of concern in Pakistan is the recent under publication authentic studies which have put the figures in IDUs at 2.5-3.5% during 2004-05. Many of these ID users are also professional blood donors in a country with inadequate blood transfusion screening; only 50% of the transfused being screened for HIV.3-12 In this background the indolent stage of disease may convert to an epidemic stage at any time, as has happened in other countries in the region.
Pakistan is a vulnerable country, with increasing levels of poverty, low levels of literacy, especially in women; low levels of condom use, low levels of awareness among health workers; a large mobile population including refugees in border areas, internal and external migrants, long-distance truck drivers known to engage in sexual practices that put them at risk of contracting HIV and sexually transmitted infections (STIs); social and economic disadvantages, particularly for women and girls, a booming commercial sex industry and widespread indulgence in commercial sex with low levels of condom use; limited safety of blood transfusion; high prevalence of STIs with limited access to good-quality STI care; unsafe medical injection and health care practices, extensive use and reuse of syringes without sterilization, including an increasing rate of needle-sharing among estimated 60,000 IDUs; and a large proportion of young people with low levels of knowledge about HIV transmission and prevention.3-12
The Government response has been positive, the first AIDS case was diagnosed in Pakistan in 1986; during 1990, the first government sponsored project for AIDS control in Pakistan was implemented with the support by the World Health Organization (WHO). In 1993, a more extended National AIDS Control Programme (NACP) was launched under a National Agenda. In 1999, the National AIDS Control Programme began working with UNAIDS. Since then, HIV/AIDS control has been made an essential element of the six major health development projects, with national HIV/AIDS strategic framework for the 2001-2006 period that sets out the strategies and priorities for controlling the epidemic.13
In the next few years, one of Pakistan's biggest challenges will be to transform the strategic plan into meaningful action. Among the difficulties will be finding ways to pay for HIV prevention and HIV/AIDS care-and-treatment programs; establishing effective partnerships and networks with donors and nongovernmental organizations; reducing the stigma associated with HIV/AIDS; safeguarding the rights of those already infected; and providing care and support to individuals, households, and communities affected by HIV/AIDS. The United Nations has warned Pakistan to avert a rapid HIV/AIDS epidemic, and that it needs urgent, coordinated, and multisectoral action in order to maintain the seemingly limited presence of the virus.3-12


Conclusion

There has been skepticism UNAIDS/WHO Working Group statistics, for fact sheets can be only as good as information made available. As these figures estimated by the working group (an annual increase of 1571%) were not associated with evidence-based strategies, but rather on reports by various institutions and agencies whose reliability was questionable, the doubt still persists. Following identical trends, and annual percent increases calculated above, there should have been an explosive HIV/AIDS epidemic in the country in 2005, this is not in evidence. Nonetheless there is no denying the fact that there has been an increase in the number of HIV/AIDS cases in the country.
My personal concern is that the inflated rates shown in 2003 by the UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, and estimates based on these figures may mask the true epidemic as and when it makes an appearance. This would be a National Tragedy and may not be very far!

References

1. CIA The World Factbook 2005, Pakistan; http://www.odci.gov/cia/publications/factbook/geos/pk ;July 2005.

2. The World Health Report 2005, Pakistan http://www.who.int/countries/pak/ en/ ;July 2005.

3. UNAIDS Country Profile, http://www.unaids.org/Unaids/EN/Geographical +area/By+Country/pakistan ;July 2005.

4. UNAIDS/WHO Epidemiological Fact Sheet http://www.unaids.org ;July 2005.

5. HIV and AIDS in Pakistan, HIV in Pakistan, AIDS in Pakistan, Indicators, Estimates, Figures, HIV situation http://www.youandaids.org/Asia%20Pacific%20at%20a%20Glance/Pakistan/index.asp ;July 2005.

6. USAID HIV/AIDS Country Profile http://www.synergyaids.com/Summaries_PDF/PakistanprofileFeb2004

7. HIV/AIDS Profile Pakistan, http://www.census.gov/ipc/hiv/pakistan ;July 2005.

8. The United Nation's Office for the co-ordination of Humanitarian Affairs, Integrated Regional Information Networks (UN OCHA IRIN).
http://www.irinnews.org/profiles/Pakistan ;July 2005

9. World Bank Country Development Gateway http://topics.developmentgateway.org/hiv/rc/Browse Content.do ?selectedRegions=87249 ;July 2005

10. U.S. Census Bureau HIV/AIDS Country Profile http://hivinsite.ucsf.edu/global?page=cr08-pk-00 ;July 2005

11. Marie Stopes International-Pakistan http://www.mariestopes.org.uk/ww/ pakistan ;July 2005

12. UNICEF Country Tables http://www.un.org/esa/earthsummit/pakis-cp ;July 2005

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: