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August 29, 2015

Pakistan needs centuries to control HIV epidemic


August 29, 2015

While missing almost all the 11 targets to eradicate HIV and having no data of 13 out of 31 indicators reflecting key features of the epidemic, the number of people living with HIV is two-time higher than the actual data reported by Pakistan to the UNAIDS taking Pakistan on the list of top 20 countries having PLHIVs, analysis of the official data shows.
Whereas Pakistan needs many centuries to control the HIV epidemic following the existing AIDS control strategies and with this budget allocation.
While analysing the data, it is found that in 2009 there were total 91,000 people who inject drugs (PWID) whereas the HIV prevalence among PWID was 20.8 percent in 2009 which rapidly increased to 27.2 percent in 2011. However, the latest data of Pakistan Bureau of Statistics (PBS) and UNODC shows that by the end of 2013, the number of PWIDs reached 4,30,000 whereas the HIV prevalence reached 37.2 percent, the second highest among PWIDs across the globe. This shows how fast Pakistan is becoming victim of HIV epidemic.
It is difficult to measure whether there has been progress or not as there has not been another round of surveillance since 2011. Out of total now 32 indicators under the 11 targets to eradicate HIV, Pakistan is reporting on 19 indicators that reflect key features of the HIV epidemic. Whereas there is no record available for reporting the remaining 13 indicators which means there are no exact figures and data available about how many people are living with HIV in the country.
The data analysis shows Pakistan has more than 3,00,000 people living with HIV but the numbers reported in the annual report are less than that. With the reported numbers of HIV positive people, Pakistan is on number 42 on the list of countries having HIV. However, the analysis shows that Pakistan must be placed among top 20 countries having PLHIVs which is proved below.
Provincial AIDS Strategies recognize acute need to bridge the gap between estimated

and actually registered numbers of PLHIV as 5.7 percent out of 13,6000 FSW received HIV test, 13.9 percent out of 43,000 HSW and only 4.8 percent out 63,000 MSW received HIV test and remaining are unaware of their HIV status. The country has no data of HIV positive pregnant women as it faced obstacles in collecting the data meaning by that no data of HIV positive pregnant women is available in the country.
As per target, 48,775 PLHIV were to be registered for the treatment of HIV but only 7,568 PLHIV which is 15.52 percent of the total target were registered with 18 centers established for the treatment. The latest data of PLHIV registered with the treatment centers of July shows that 8,613 PLHIV have been registered. The report further reflects the grim picture as by the end of 2013 none of the provincial governments except Punjab had prepared any project to fight this epidemic. Except Punjab, no province approved PC-1 for the AIDS control whereas the country is spending around $8 on HIV activities in per capita terms annually. A country which is fast growing in HIV epidemic, the legislative environment remains mostly unsupportive of the needs of those vulnerable and at risk and those already living with HIV. An HIV Policy and an HIV Act were developed in 2007 but have not yet been approved by Parliament.
As per annual report of Pakistan’s National AIDS control programeme, 83,468 people are living with HIV by the end of 2013 and 7,568 PLHIV are registered in 18 HIV centers across the country. Out of these, 3,211 adult PLHIV and 70 children were on ART. According to this data, the key population estimates in Pakistan in 2009 was, 91,000 People Who Inject Drugs (PWIDs), 42,877 Transgender/Hijra Sex workers (HSW), 62,636 Male Sex Workers (MSW) and 136,300 Female Sex Workers (FSW).
The data in the report claims that after the PWIDs, the HIV prevalence in Hijra Sex Workers is second highest with 5.2 percent in 2011 whereas 1.6 percent among MSW and 0.97 percent in FSW. When we compare it to the HIV prevalence recorded in 2008 it has raised significantly in each category as HIV prevalence in PWID was 20.8 percent, in FSW it was 0.2 percent and in MSW the HIV prevalence was 0.9 percent which suggests that there has been a clear rise in prevalence in the next three years.
However, according to a survey conducted by Pakistan Bureau of Statistics and United Nations Office on Drugs and Crimes (UNODC), the number of People Who Inject Drugs (PWID) is estimated to be 430,000 nationwide, or 0.4 percent of the total population. Among PWID, 73 percent reported sharing syringes. From a health perspective, injecting drug use is considered to be the most problematic route of drug owing to the high risk of acquiring and spreading HIV and other blood-borne infections.
If we further analyse the data by calculating the existing PWIDs and the HIV prevalence ratio, it shows that by the end of 2013 as per PBS and UNODC data out of 430,000 almost 159,100 PWIDs have HIV prevalence as the ratio of prevalence among PWID was recorded by 37.2 percent. However the official data shows that there are 83,468 people living with HIV in the country which is almost half of only one high risk factor i.e. PWID.
Approximately 30 percent of people that inject drugs are married which means 130,000 out of 430,000 PWID are married. This means 130,000 PWIDs who are the potential HIV careers are risking their families by sexually transmitting the HIV to their spouses and even their kids are hidden pockets of HIV.
When this correspondent further analysed the data, according to which 73 percent out of total, 430,000 drug users share their syringes with two to three PWIDs which means 313,000 are vulnerable to the spread of HIV or other blood-borne diseases i.e. hepatitis. As per data only 9.1 percent of those who received HIV test know about their results whereas 90.9 percent PWID i.e. 3,87,000 do not even know about their status of HIV posing high risk of HIV transmission to other injectors and partners. If we further analyse the data of those PWID who have not received their HIV test then as per HIV prevalence ratio of 37.2 percent, 1,43,996 more PWID are potential HIV positive. The data calculation suggests that 303,096 PWID are potential HIV positive which is even more than two times higher than the actual numbers.
Dr. Abdul Baseer Khan Achakzai, Programme Coordinator of National AIDS Control Programme, however contradict the projected total number of PLHIV and said he did not agree with the numbers presented by UNODC and Pakistan Bureau of Statistics as UNODC works on drug related issue and how their data could be authentic for AIDS.
As per report 42,877 Transgender/Hijra Sex Workers are working in the country and they have the second highest HIV prevalence ratio i.e. 5.2 percent. However only 10 percent i.e. 4, 288 of the total HSW have tested for HIV and the remaining 90 percent i.e. 38,589 HSWs are unaware of their HIV status. Similarly the data shows that more than half (55.1 percent) HSW reported using alcohol and/drugs during sexual intercourse in the past six months. Overall, 10.1 percent of HSW reported to have had sex with PWID in the past six months, whereas 3.4 percent HSW reported that they had been injecting drugs in the same time period. As per existing prevalence ratio almost 2229 HSW are HIV positive.
The estimated total number of MSW in 2009 was almost 63,000 with the majority also found in larger cities. As per calculations only 22 percent of MSW interviewed had ever been tested for HIV and the remaining 78 percent are unaware of their HIV status. The ratio of HIV prevalence among MSW is the third largest in the country.
With an estimated population of over 136,000 in 2009, 64.3 percent of FSW reported being married. The ratio of safe sex with their clients is only 33.2 percent which means the remaining 66.8 percent of the total 136,000 are vulnerable to HIV. The data analysis further suggests that 39 percent of the total sex workers reported using alcohol or drug while performing sex with their clients whereas 15.8 percent had sex with PWIDs and 7.5 percent also inject drugs. The data also present very alarming situation particularly when only 15.7 percent female sex workers had HIV test whereas the remaining 84.3 percent are unaware of their HIV status.
With such a high HIV prevalence ratio in the country the national as well provincial governments were required to take emergency steps and allocate more funds to control this epidemic. However neither the national nor the provincial governments have actively participated in the programme. As per report Pakistan received $28 million grant from Global Fund and an additional $19 million was requested for the continuation. However none of the province except for Punjab approved the PC-1 which shows lack of seriousness by the provinces.
Similarly there was a need of legislative support to the people living with HIV so that the other people who are vulnerable to HIV should be encouraged to go for HV test. But the HIV Bill which was developed in 2007 is still waiting to be passed by the parliament. Hence the discrimination and stigma factor became a major hurdle in motivating the people to go for HIV test. According to the report Pakistan is not even on track to reach this target and only 15 percent men and 17 percent women expressed accepting attitude towards people with HIV.
According to the experts, the procedure of budget allocation and expenditure in the country is haphazard as the main focus is being paid and major spending is being identified for the care and treatment purpose. There is a little share of expenditure for an enabled environment i.e. social protection and services, key for a successful HIV response in a concentrated epidemic.
As per report the country is spending around 8 US dollar on HIV activities in per capita terms annually. According to the budget estimates of 2013, Global Fund contributed 50 percent of the total expenditure on AIDS Control Programme. Similarly provincial government shared 37 percent, the UN 7 percent, other external donors 3 percent and national government 3 percent of the HIV response.
The data also shows that Pakistan has also failed to reach the target of eliminating mother to child transmission of HIV by 2015 and in its annual report it is mentioned that the country is not even on track to meet his target. The report says that Pakistan has faced obstacles in finding the most effective approach to reach HIV positive pregnant women; therefore the total number of registered mothers is low as compared to the national estimates.
The data analysis as well as the National AIDS Control Programme, UNODC and Pakistan Bureau of Statistics suggest that Pakistan’s epidemic is driven mainly by PWID. However, the data from all studies indicates a risk overlap of PWID with sex workers and other clients. As per target, it was the responsibility of the national as well as provincial AIDS strategies to making prevention of sexual transmission a priority intervention for 2012-16, with a target to reach 60 percent of MSW, FSW and HSW with HIV prevention services. However instead of this only 15 percent could be reached so far which is far below the target.
According to the report, Pakistan even has no data to know the percentage of young people aged 16-24 living with HIV whereas no population-based demographic or other national surveys include this question so far.
“The UNAIDS has not adopted the survey report of UNODC and he would be able to comment on the figures of UNODC if it is adopted and accepted by UNAIDS. The major concern for National AIDS Control Programme is gap between the PLHIV and number of HIV positive registered for the treatment as almost 12,000 people are registered for treatment and still a huge number is yet to be registered,” commented Dr Baseer.
When asked why the National AIDS Control Programme is focusing only on treatment and no attention is being paid on stigma removal, he said they already have given a project of HIV stigma removal and ending discrimination to Association of People Living with HIV (APLHIV) which is working on this issue. Similarly another NGO Nai Zindagi is working on PWIDs and major funding of Global Funds (GF) is going to this organisation. Only 30 percent of the GF is being given to National AIDS Control Programme and remaining 70 percent to Nai Zindagi, he said.
He, however, informed that the provincial governments have allocated Rs3.2 billion ($30.2 million) for this programme and except of Khyber Pakhtunkhwa each province has approved their PC-1.
When asked no survey on HIV conducted after 2011 then how this data is authentic, Dr Baseer said recently they have started survey and Punjab has already started working on it. So far Punjab government has conducted survey in 10 districts and the remaining would be done soon however there are a few restrictions because of social binding due to which each indicator could not be covered.

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