The Human Immunodeficiency Virus [HIV] epidemic is spreading in Pakistan. According to a recently-released report by UNAIDS, in 2018, the incidence of new HIV infections among young people (aged 15-24 years) increased by 29% and overall among all ages by 13 percent.

Last year, 22,000-24,000 new HIV infections were reported. In 2017, the number was 21,000. Based on the current estimate for 2018, it is expected that reports will show the number to have risen by 160,000-190,000. The number was 120,000 in 2015 and 67,000 in 2010. This shows that since 2002, the incidence of HIV infections has been on the rise. The UN report has pronounced the current situation in Pakistan to be a ‘concentrated epidemic’.

The ‘concentrated epidemic’ label means that HIV prevalence is consistently over 5 percent, but below 1% among pregnant women in urban areas, and that it has spread rapidly in one or more defined subpopulations but is not yet well-established among the general population.

The report reveals that people living with HIV (15 years of age and above) include 48,000 women and 110,000 men. The number of children (individuals under 14 years) living with HIV stands at 5,500. The report states that between 6,400 and 7,600 adults and children died due to AIDS during 2018.

HIV and AIDS [Acquired Immunodeficiency Syndrome] are related, but not the same. HIV is a virus that may lead to AIDS, a disease you can get after the virus has infected your body for several years and weakened your immune system. Not everyone who has HIV will get AIDS, but without treatment with antiretroviral drugs, the infection will eventually exacerbate to AIDS. According to the World Health Organisation, this process usually takes 5 to 15 years.

Dr Sikandar Warraich is based at the Sargodha district headquarters hospital (DHQ). He treats HIV patients. He says that many people with the virus don’t know they have it as they have never been diagnosed.

"Your immune system has cells called CD4 or T cells that help keep you healthy. HIV attacks these cells. The virus copies itself over and over, reducing the number of CD4 cells in your body. Without that armour, you become more vulnerable to bacterial and viral infections. Early diagnosis allows antiretroviral drug therapy stops the destruction of CD4 cells as there is no cure for HIV infection or AIDS", he explains.

Shameem Bibi*, who lives in a village close by, fell sick and was brought to the hospital. Here, she was diagnosed with the HIV infection. Dr Warraich tells TNS that to trace the source of Shameem’s infection, her husband’s blood was also tested. "The story behind Shameem’s infection connects to her husband’s. He was deported from a Gulf country because he was found to be a carrier. But, he didn’t disclose the reason behind his deportation."

The infection had spread to Shameem through him.

Because of availability of medical treatment, the couple are now living a better life. Dr Warraich believes that there may be many families in and around Sargodha with similar stories. "Certainly, the taboos, lack of awareness, lack of contraceptive usage, and insufficient medical facilities are resulting in more HIV patients."

The Ministry of National Health, has an estimated figure of 165,000 HIV patients of which approximately 75,000 are in the Punjab, 60,000 in Sindh and around 15,000 in the KP and Balochistan. However, according to National AIDS Control Programme (NACP), the total number of registered HIV/AIDS patients is 24,331, and out of these 17,149 are receiving treatment.

"The causes behind HIV infection include infected injections of drug users; use of a syringe more than once by quacks; unhygienic tools of footpath dentists; unsafe blood screening and infusion; lack of separate dialysis machines for HIV or AIDS patients etc", says Phoenic Foundation for Research & Development Chief Executive Officer Dr. Noor ul Zaman Rafiq. Female and transgender sex workers are particularly vulnerable as their work jeopardises their sexual health. With HIV/ AIDS on the rise, the situation becomes even more concerning.

In 2018, the Pakistan Field Epidemiology Training and Laboratory Training Programme (FELTP) conducted an investigation and found out that all over Pakistan, many quacks were using the same syringe on multiple patients. World Health Organisation (WHO) points out blood transfusion as another source of HIV spreading in Pakistan. It is estimated that 40 percent of the 1.5 million annual blood transfusions are not screened for HIV. About 20 percent of the blood transfused comes from professional donors.

The UNAIDS 2016-17 data records 5.5 percent HIV prevalence amongst 52,646 transgender people at national level; the highest prevalence is in Larkana with 18 percent. The data also shows that approximately 832,213 men had sex with men with 3.7 percent prevalence - Karachi stands at 9.2 percent; and 2.1 percent prevalence has been found in approximately 228,787 female sex workers - Sukkur leads with 8.8 percent.

The United Nations Office on Drugs and Crime (UNODC) 2017 analysis report has documented that Pakistan has 6.7 million drug users: 4.25 million of these are addicts. The UNAIDS report’s statistics show that there is a 21 percent prevalence in PWID (People Who Inject Drugs). Kasur is worst hit with 50.8 percent prevalence. "Unsafe injecting practices are a major risk factor for the transmission of blood-borne infections such as HIV and viral hepatitis B and C", says Dr Rafiq.

The United Nations General Assembly took up this issue in 2016 during a high-level meeting focused on what must be done to achieve the goal of ending AIDS by 2030. A panel of experts advised that "ending the public health threat of AIDS" can be interpreted quantitatively as a 90 percent reduction in new HIV infections and deaths from AIDS-related illness by 2030 (compared to 2010 baselines).

Since health is a provincial subject in Pakistan after 18^th Amendment, any efforts at ending the stigma of HIV would be a provincial subject now. Punjab Aids Control Programme (PACP) Spokesperson Sajjad Hafeez claims that the Punjab is on track in terms of achieving the target of keeping the HIV epidemic at less than 0.1 percent by 2030.

"To accomplish this target, preventive services and treatments along with voluntary counseling, and testing centres are being provided to HIV patients in ten districts. Moreover, trainings for healthcare providers, paramedical staff and other stakeholders are being conducted regularly for better service-delivery to patients. Rigorous awareness campaigns are also being run to spread awareness among general public and patients", he explains.

Dostana Organisation Programme Manager Dr Usman Ali expresses discontentment with the efforts of PACP. "There are 36 districts in the Punjab. Running treatment centres and offering preventive services in only ten cities shows a lack of seriousness of the state in fighting this epidemic. Also, the HIV Bill is still pending in the Punjab Assembly though it was passed by Sindh in 2013."

There are around 50 NGOs involved in creating public awareness about HIV/AIDS and also providing support to HIV/AIDS patients. These NGOs are members of the Provincial HIV/AIDS Consortium, which has been established in all four provinces to coordinate HIV/AIDS prevention and control activities.

"However, these organisations are reaching out to less than 15 percent of the vulnerable population. People in the rural areas of Pakistan are mostly uneducated which is one of the possible reasons for HIV spread", Ali states "There is hardly an example of being effective at grassroots level to promote preventive measures or create mass awareness regarding the stigma prevailing in the society towards HIV patients."

Dr Rafiq emphasises the state’s duty in this situation. "Unfortunately, international organisations are not currently offering adequate donations to Pakistan. Therefore, it is the state that needs to play the most important role in saving the future."

 *Name changed to protect the patient’s identity.