Learning from Ratodero

A year ago, Pakistan was put under the international spotlight because of the HIV outbreak in Ratodero, Larkana in Sindh that infected over =a thousand children under 15 years of age.

The Sindh government quickly led the mobilization of resources, both local and international, to fully investigate the HIV outbreak. After eight weeks, the WHO-led outbreak investigation team released its report. This then informed the development and implementation of the Sindh HIV Outbreak Response Plan.

Less than a year later, another devastating unprecedented outbreak of a global scale, the Covid-19 pandemic, is affecting Pakistan along with most of the world. Unlike the HIV outbreak, where everyone was shocked and unprepared, the Covid-19 crisis started slowly at first from other countries before gathering momentum, thereby allowing some precious lead time for the government leadership to prepare.

As I ponder over this evolving crisis that has literally locked us down, let me share some learnings from the HIV outbreak response that could likely be applied in the Covid-19 response.

First, political leadership from the very top is central for action. The Sindh government, particularly the Department of Health’s quick and courageous action, changed the course of the HIV outbreak. I have witnessed how the Sindh minister of health professionally managed the crisis. Numerous dialogues, some difficult, were carried out with federal and local health officials, community, families affected, professional groups, and development partners. The Sindh government set aside political affiliation, and reached out for national and international technical support to complement the provincial efforts.

Second, solutions to difficult and complex problems could be found if people living with and affected by HIV in the community are meaningfully engaged. When addressing the HIV outbreak, it was imperative to continuously confer with the local members of the community infected and affected by HIV, and local leaders from religious groups, law-enforcement agencies, academia, media, non-government organizations and development partners. Their understanding of the local cultural context and collective wisdom significantly contributed in finding and implementing immediate and long-term local solutions.

Third, the health sector alone cannot address it. Multisectoral, multilevel response is critical. Vast experience has shown that no single entity could effectively address HIV and its related issues. Joint, collective and coherent effort is important. The multifaceted response to the Sindh HIV outbreak, although far from perfect, could serve as a prototype for Pakistan’s future response to growing crises and epidemics, including Covid-19. With the health services devolved to the provincial level, this becomes even more relevant.

Four, within the health sector, integration of HIV services will enhance efficiency gain. Most of the children who acquired HIV during the outbreak, had concomitant health problems, including malnutrition, respiratory illnesses, and parasitism. They came from far-flung rural areas and some would require a full day’s walk to reach the district clinics. In most instances, the various services are housed in different locations. While integration of services including pediatric care is a challenge facing the broader health systems, if the aim is to provide comprehensive coverage of essential HIV intervention, then the operationalization of an integrated, one-stop-shop approach should be done with urgency.

Five, timely generation and analysis of data in informing the evolving response is essential. People who heard about the HIV outbreak in Ratodero were almost mobbing the hospital demanding to be tested. Some of the people I talked with did not know what HIV is about but because they heard from their neighbours, they insisted on being tested too. The recording, reporting and monitoring system were chaotic at that time. It was a daunting challenge to organize the system and rapidly build capacities of medical and auxiliary staff. For example, data on those tested positive and enrolled in treatment were difficult to get on time, hence it was an arduous job to design and adjust the plans, including the logistics. But gradually it is improving. In the beginning, less than 30 percent of HIV positive children were enrolled in treatment. To date, 87 percent are now on life-saving treatment.

Six, media partners could make or break the response. During the HIV outbreak, we witnessed how media practitioners were filming HIV positive children showing their faces, some even following their families up to their houses in the villages with their video on. This unethical behavior was unacceptable. It brought to light the darkness of stigma, discrimination and prejudice, the very elements that fuel the effective spread of HIV. This situation led to the Sindh AIDS Control Program’s (SACP) educational program for media practitioners that eventually gave birth to the Sindh Health and HIV Media Alliance. Currently, the SACP is tapping into this Seven, the government’s regular interaction with the media, is invaluable. This approach was very helpful particularly in addressing fake news, prevailing myths and misconceptions. During the HIV outbreak, the Sindh DoH had appointed a media coordinator who helped organize regular press briefings and released media advisories. This effectively informed the community about what actions were being taken, the progress and the gaps, thus generating community confidence in the leadership of the provincial government. It likewise helped in advocating for additional resources and investments, to narrow or even close the resource gaps.

Eight, sharing and using local resources smartly could generate more long-term dividends. Resources will never be enough. There were and will always be competing priorities. The Sindh DoH first reviewed and utilized its existing provincial resources. Then they started mobilizing additional resources to complement their investments. Several philanthropists, locally and overseas, offered support. The provincial leadership created an endowment fund of one billion rupees for children infected with HIV during the outbreak.

Capacities of health workers on several fronts continued to be built, and systems to monitor progress and ensure non-disruption of supplies and quality services were being established. Like the HIV outbreak, the Covid-19 crisis offers a strategic opportunity to inter alia, further strengthen health and community systems, enhance governance, and maximize integration with existing social welfare program such as Ehsaas, to ensure an effective, efficient and sustained response.

Finally, something valuable and beneficial for the people could emerge from outbreaks. Before the outbreak, HIV was at the backseat of the government’s priority agenda. Tragic as it was, the HIV outbreak was a wake-up call for action, and it has made HIV one of the priority health programs now. It unified the whole country in prioritizing and investing in efforts to stop HIV transmission and to ensure universal access to life-saving treatment and care services. It was also clear that investments on programs in infection prevention and control and blood safety needed to be aggressively pursued, both in policy pronouncements and in implementation. Otherwise, the currently “concentrated” HIV epidemic profile of Pakistan could quickly move to the general population, increasingly infecting children and women.

I went back to Ratodero six months after the HIV outbreak. It was very encouraging to see tangible improvements, including the establishment of a one-stop-shop HIV treatment hub. Efforts to implement the response plan are ongoing. Continued monitoring is critical, implementation bottlenecks need to be addressed, and progress needs to be documented.

For both HIV – which has been around for almost four decades now – and Covid-19, just a few months with us, vaccines and cure are not yet available. Prevention – coupled with empathy, compassion and determination – therefore remains the best weapon to fight both.

The writer is currently the UNAIDS country director for Pakistan and Afghanistan.

Email: borromeom@unaids.org