Revitalizing the HIV response in Pakistan: A systematic review and policy implications
ABSTRACT We sought to describe the epidemiology of HIV in Pakistan and prioritize interventions to improve the effectiveness and efficiency of the response to HIV.
We conducted a systematic review of the epidemiology of HIV in Pakistan. Data sources included PUBMED and EMBASE and unpublished reports from public, non-governmental organizations and provincial and national stakeholders. We focused on findings from the last 5 years and only evaluated data before 2005 on at risk groups where there were insufficient data published after 2005. A population attributable risk analysis was conducted to estimate the burden of HIV among most at risk populations (people who inject drugs, female sex workers, male sex workers, Hijra or transgender sex workers and men who have sex with men).
Pakistan has a concentrated epidemic of HIV-1 among most at risk populations with very low prevalence rates in the general population (0.04%). The majority of current HIV infections are estimated to occur among four at risk populations, despite their accounting for under 2% of all adults. Injecting drug users accounted for 36.4% of HIV cases - the largest share of infections in any one group. Female, male and transgender sex workers accounted for 24%, 12% and 17.5% respectively, a cumulative population attributable risk of 53.5% of all infections occurring among sex workers.
Pakistan must continue to invest in targeted, evidence-based interventions to prevent the spread of HIV and curb the epidemic trajectory in Pakistan. A comprehensive range of services should include needle and syringe exchange, opiate substitution therapy for people who inject drugs, outreach and engagement with injecting drug users, Hijra' community as well as male and female sex workers and their clients and improved linkage between services and voluntary counseling, testing and anti-retroviral therapy.
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ABSTRACT: Oral preexposure prophylaxis (PrEP) has shown HIV preventive efficacy for several key populations at risk for HIV infection including MSM and heterosexual men and women in HIV serodiscordant relationships. An efficacy trial of daily oral tenofovir among people who inject drugs (IDU) is underway in Thailand. Although efficacy data is pending, there is emerging biological and public health plausibility data suggesting the utility of PrEP as an effective component of combination HIV prevention for IDU. Drawing from studies characterizing adherence to antiretroviral therapy for IDU, there are a range of scientific and operational considerations for the potential use of PrEP for IDU. We review here the available literature on the potential use of PrEP for IDU, barriers to uptake and adherence, and potential implementation science questions, which could address, and potently increase, the effectiveness of this intervention. IDU remain the most underserved population in the HIV response worldwide, and have a marked gap in prevention services, making PrEP a potentially promising addition to the prevention toolkit for people who use drugs and, for those already living with HIV infection, for their spouses and other sexual partners.Current opinion in HIV and AIDS 11/2012; 7(6):563-8. DOI:10.1097/COH.0b013e328358e49e · 4.39 Impact Factor
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ABSTRACT: The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted. We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion. Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3-14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (ARR = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04). Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009-2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.PLoS ONE 12/2013; 8(12):e81715. DOI:10.1371/journal.pone.0081715 · 3.53 Impact Factor
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ABSTRACT: Background & Objective: Although the magnitude of HIV in Pakistan has been well documented, but no record of HIV prevalence in Faisalabad region exists. A retrospective study was carried out at Sexually Transmitted Infections (STIs) clinic, District Headquarter (DHQ) hospital, Faisalabad, Pakistan to find out the prevalence of HIV and related risk factors. Methods: Between March, 2010 and December, 2012, a total of 31040 subjects were either interviewed or their medical records were reviewed. From those recruited by convenient sampling method, written informed consent was obtained and informed about the study protocol. Blood serum was tested for antibodies to HIV-1 and HIV-2 (Enzyme-linked immunosorbent assay, Western Blot). Results: On the whole, Anti-HIV was demonstrated in 173 (0.557%) of the respondents. This gives an overall HIV prevalence of 557 per 100,000.Averaged age of the patients was 49.5 years (range: 30-45) with 85.55% male. Majority of the patients were urban dwellers (87.28%), divorced or widowed (46.82%) and uneducated (50.28%). A large proportion (78%) of the patients was injection drug users. Compared to blood donation/transfusion and sexual interactions, injection drug use was the major potential risk factor for HIV infection. Conclusion: Most important finding was higher HIV prevalence in Faisalabad region as compared to the previous assessments at the national level. This reflects an alarming situation necessitating contextual preventive interventions. Precarious practices such as injection drug abuse, blood donation/transfusion needs to be amended and extramarital sexual contacts should be avoided.Pakistan Journal of Medical Sciences Online 03/2014; 30(1):32-5. DOI:10.12669/pjms.301.4176 · 0.10 Impact Factor