Special report: The making of an HIV catastrophe
Resurgence of HIV in Pakistan
By: Faiza Ilyas and Ikram Junaidi
KARACHI/ISLAMABAD: In October 2016, it was reported that more than 50 patients on renal dialysis at the Chandka Medical College Hospital (CMCH) in Larkana had contracted the Human Immunodeficiency Virus (HIV).
The Journal of Pakistan Medical Association put the total figure at 56. It was also learnt that 36 patients had contracted HIV and hepatitis C, whereas two tested positive for hepatitis B.
Since, seven patients have died due to complications over the past ten months.
Inquiries into the CMCH incident reveal that most patients had a history of multiple blood transfusions conducted at the hospital; and that private blood banks in the vicinity operate without adhering to quality assurance methods.
Sources at the hospital — which also has an HIV/AIDS care and treatment centre — explain that the dialysis unit prior to the incident did not have a laboratory to screen patients.
Moreover, hospital staff relied on dubious lab reports [for blood tests] that patients brought with them.
Regrettably what might have been an opportunity for action was another episode of official indifference.
When Dawn contacted Dr Hola Ram, in charge of the HIV/AIDS care and treatment centre at CMCH, he confirmed, “The total number [of infected patients] was 50; three to four patients refused to receive antiretroviral therapy, while the rest are on HIV treatment.”
However, last year when the inquiry committee was writing its report, 26 patients were infected with HIV, he said.
Moreover, two out of three blood banks sealed after this incident were later declared ‘safe’ and allowed to operate by the Sindh Blood Transfusion Authority (SBTA).
However, the CMCH, a 1,500-bed tertiary care hospital still does not have a blood bank. Sources at CMCH also told Dawn that the sale of blood by injecting drug users continues unabated in the district.
Donors are clandestinely approached by agents at night mostly to for urgent blood donations.
Months into the incident recommendations made by the inquiry committee in October 2016 remain unimplemented, including the appointment of a nephrologist at the hospital and the curtailing of sub-standard laboratories.
Also, patients who contracted HIV at CMCH complain that they have not been compensated by the government.
“The incident brought a bad name to the government. Worse still, all those responsible for the HIV outbreak — officials from the Sindh AIDS Control Programme (SACP), the SBTA and even the medical superintendent of CMCH — were part of the inquiry committee,” says a health expert on condition of anonymity.
Dawn repeatedly contacted the SACP manager and the SBTA secretary for their comments but both did not respond.
An investigation report into the Larkana incident by the National Aids Control Programme — which reviewed HIV/Aids treatment centre data at CMCH from February to August 2016 — states that while an average of 29 new HIV patients registered each month at this facility the ratio of those who sought treatment was recorded at 19.4 per cent.
Larkana has witnessed rising numbers of HIV cases since 2003 when the first outbreak among injecting drug users was reported.
At that time, a survey cited 17 out of 175 injecting drug users as HIV positive.
Certain varying factors have also contributed to the rise in HIV in Larkana, including its active population of sex workers, especially male-to-male sex workers, and injecting drug users.
It is unfortunate that in a province where almost half of the country’s HIV infections have emerged, patients are compelled to travel to Karachi that has one HIV referral laboratory.
“The Larkana incident is reflective of how HIV is spreading in the country, especially where regulatory health control mechanisms and treatment are absent.
And, while, unscreened blood transfusions and the lack of infection control practices is common, there is still silence on this,” an infectious disease expert explains.
According to medical experts, aside from the fact that HIV infection takes a long while to show signs, physicians’ lack of awareness, the social stigma attached to the disease and the reluctance of government officials to document exact numbers of infected people are contributing factors that veil the truth about the rise of HIV.
In other words, the Larkana incident provides some explanation for the rise in HIV among communities most at risk.
New HIV infections
With about 133,529 people estimated to have contracted HIV, Pakistan is one of few regional countries to witness an increasing number of cases.
Hopes for successfully tackling the disease are overshadowed by extremely low HIV screening and treatment coverage, and rising numbers of new cases.
With the country’s HIV/AIDS control programme about to receive a renewed three-year (2018-2020) $35 million grant from the Global Fund for Aids, TB and Malaria (GFATM) — a financing partnership organization — those registered as HIV positive must be ensured access to free medication and treatment options.
Antiretroviral therapy (ART), a life-saver, stops the virus from making copies of itself and attacking the body’s immune system.
“The reasons for new infections, include the lack of political will, bureaucratic hurdles, the stigma attached to the disease, the absence of treatment and technical facilities and trust deficiency [between implementing stakeholders],” explains Dr Baseer Achakzai, the manager of the National Aids Control Program (NACP).
More alarmingly, the Integrated Biological and Behavioural Surveillance for 2016-2017 by NACP conducted in 23 towns/cities shows that the high prevalence of HIV is no longer confined to injecting drug users and transgenders, but, has taken the form of an epidemic in other high-risk groups as well – prisoners, men having sex with men and male sex workers.
This increase can also be traced to growing numbers among other segments, such as female sex workers, migrant workers returning from the Middle-East as well as those people contracting HIV through unsafe blood transfusions and drips.
With treatment coverage remaining very low, the critical question is whether donor money is equitably distributed.
“The way the HIV/AIDS programme is currently administered in the country is a sheer waste of money,” says former SACP director, Dr Sharaf Ali Shah, who heads the Bridge Consultants Foundation, an implementing partner working with NACP and New Zindagi Trust (NZT) – a non-governmental organisation serving as a principle GF grant recipient since 2011.
Globally, HIV control programmes are integrated with other healthcare strategies. Referring to the lack of free drug rehabilitation centres in Karachi, he explains, “this highly marginalised group of drug users at the core of the HIV epidemic has serious psychological and social issues.
If you don’t address them, they won’t adhere to treatment and that can lead to relapse, resistance against the drugs.
Besides, wives and partners can get infected. We also require proper facilities for detoxification therapy.”
With Karachi identified as one of the top cities in the world with a worrying rise in HIV prevalence, it is critical to control the disease before it spreads further.
High-risk population groups
Sexual transmission among men will account for the bulk of new HIV infections, if intervention remains at current levels, according to UNAIDS.
Moreover, whilst female sex workers have the lowest prevalence among key population groups (2.2pc), their rate is increasing at the fastest pace (up by 2.67pc from 0.6pc in 2011).
Transgender people have the highest overall HIV prevalence rate (7.1pc) among key populations for whom sexual transmission predominates.
The highest prevalence rate for transgenders was reported from Larkana (18.2pc) followed by Bannu (15pc) and Karachi (12.9pc).
In Khyber Pakhtunkhwa (KP), for example, Dawn has learnt that the HIV control programme will begin providing counselling, testing services and treatment to transgenders in July.
According to Dr Ayub Roz, head of KP’s HIV control programme, Rs 200m is available for preventive measures and treatment for transgenders.
With an estimated 9,000 HIV patients, lack of funding had halted the KP Aids control programme.
Although entitled to grant money from the NACP, KP had failed to meet essential requirements – including submitting a PC-I for projects, says Dr Achakzai, though this year funding will be disbursed after GF approval, he confirms.
With Rs300m for the HIV programme, only Rs30m was released in 2016-17 – money spent on offices and hiring staff, say sources.
Meanwhile, the government’s inability to convince stakeholders to allow the use of opioid substitution therapy, a proven intervention allowed by the World Health Organisation and a critical part of the detoxification therapy for drugs users with HIV poses another barrier. Where is Global Fund assistance going?
Since 2000, GF has contributed 80pc of funding for the country’s HIV program while the government provides 20pc.
According to Tariq Zafar, the executive director of NZT, the trust receives around $5m annually ─ it has received $17.45m over the past three years.
GF has ranked the trust at A2 level which means near 100pc, he says.
Explaining the procedure to qualify for a grant, Dr Achakzai says GF forms a country coordination mechanism (CCM) including representation from concerned ministries, departments and civil society.
“Concept notes are sent from the government and private organizations (NZT) by CCM to GF for approval. NACP transfers funds it receives to the provinces,” he explains.
Similarly, NZT disburses GF money to sub-recipients – three in Sindh, two in Balochistan and similarly, private not-for-profits are provided funding in Punjab and KP.
Without a GF representative in Pakistan, the United Nations Office for Project Services (UNOPS) serves as the local fund agent.
According to Dr Achakzai, it verifies accounts and reports to GF every six months.
“We have observed that the local fund agent raises objections regarding NACP accounts, but ignores discrepancies in private sector accounts,” he claims.
“Often the NACP will face objections over a transaction of Rs 1,300, for example, but bills from the private sector that amount to Rs 1.3m with the same objections are cleared,” he adds.
Sources at NACP also told Dawn that concept notes by NZT are forwarded to GF without detailed evaluation.
On his part, Mr Zafar explains that “although GF sends us money, our concept notes are approved by the secretary for the ministry of national health services.”
He says that a quarterly audit is also conducted, claiming that because NZT conducts a detailed audit of sub-recipients that “they remain annoyed with us.”
Between July 2014 and December 2016, GF contributed $9.023m for Pakistan’s HIV programme.
Out of which $1.3m was spent in Punjab, $0.84m in Sindh, $0.43m in KP and $0.36m was spent in Balochistan. Moreover, $0.2m was also given to the Association of People Living with HIV which has worked in collaboration with the NACP.
Despite these allocations, insider sources say it is a difficult task to get the government to provide funding to the provinces.
And KP’s dormant HIV control programme serves as an example.
Interestingly, though Dr Achakzai says the HIV program has never had financial hiccups, he admits that government funding is rare.
“It is embarrassing to reveal, but it is a fact that NACP staff has not received salaries for the last 10 months because funds could not be released. There is political will to eradicate polio, but, unfortunately there is none to prevent and treat HIV. Although HIV is a bigger health catastrophe compared to polio in this country. If at any time GF stops funding this programme, within a few weeks, we will not have a single tablet for HIV patients,” he explains.
Additional reporting by Ashfaque Yusufzai in Peshawar and M B Kalhoro in Larkana.