Bloodborne HIV: Don't Get Stuck!

Three Headed Monster

HIV is not the only threat from unsafe healthcare. Pakistan has one of the worst epidemics of hepatitis C in the world due to unsterile practices in healthcare and cosmetic services. Hepatitis B is also common. In this link, Sohail Rabbani characterizes hepatitis B, C, and HIV as a Three Headed Monster threatening Pakistan. The same monster threatens other countries.[1] A 2021 journal article overviews the outbreaks noted here.[1a]

Ratodero, 2019

In February 2019, a private doctor recognizing immune deficiency in a 1-year old girl sent her for an HIV test; she was HIV-positive but her mother was not. Over the next several months, he found more HIV-positive children with HIV-negative mothers. Government doctors, although aware of these infections, did nothing until the media picked up the story on 24-25 April.[2] With public and media pressure, officials in Larkana, Sindh Province, began to investigate, arranging for HIV tests on demand. Through end-November 2020, the official investigation reports 42,533 tests found 1,540 to be infected (1,132 children aged 0-15 years, 286 women, and 121 men).[2a] (Because HIV has been rare among women in Pakistan, many women found HIV-positive in the investigation likely got HIV from breastfeeding their babies infected from health care.) Numbers continued to rise: As of early March 2023, “around 2,800 children have so far tested positive for HIV” in and near Ratodero.[2b] Dr Ershad Kazmi, Communicable Disease Control, Department of Health, Sindh, reports ongoing nosocomial transmission in and near Ratodero[2b]: “We are doing massive screening and testing in the area and due to that, every day several people including adults and children are testing positive for HIV. This outbreak in 2019 was in general population due to poor IPC and use of infected needles and syringes, which is still the main cause of HIV spread in the area.” Poor infection prevention and control (IPC) is an ongoing reality with quacks as well as “general practitioners, private hospitals and even the small healthcare facilities except some of the leading tertiary-care health facilities in these districts.” (Mainstream media have published many other reports of this outbreak, for example [3a][3b][3c].)

Kot Imrana, near Kot Momin, Sargodha, 2018-19

In January 2019, the Health Department found 669 (13.4%) of 5,000 residents of Kot Imrana were HIV-positive.[4] HIV prevalence was higher in women and children. “[A] quack was found to have used the same syringe on multiple patients.” There are many quacks in the region. “[B]arbers are the other sources of HIV transmission because they use contaminated razors and blades.”[4] Almost one year earlier, in early March 2018, the Pakistan Observer reported “elders of the area [Kot Imrana village] brought the matter [of many HIV-positive residents] to the knowledge of the Punjab government.”[5] Responding to local concerns, the health department drew and sent blood from 2,757 residents for HIV tests. By mid-March 2018, tests found 204 (14.5%) of 1,406 persons to be HIV-positive.[6] In mid-March 2018, The local District Health Authority Chief Executive Officer Dr Nusrat Riaz “told the publication [Pakistan Today] that the disease had mainly spread in the area due to the use of one syringe on multiple [people] by a local quack.”[7]

While the press in Pakistan had already reported a serious problem by March 2018, in June 2018 — three months later! — Lancet Infectious Diseases, a leading international journal, misleadingly reported only 1.29% HIV prevalence in the village.[8]

Chiniot, near Sargodha, 2017

After initial reports of HIV in a village near Chiniot, health officials set up a camp to test residents. Seventy came for tests, of which 42 tested HIV-positive: 27 women, 17 men, and a 7 year old girl. The article reporting these infections quotes a doctor:  “It’s a misconception that HIV is contracted because of sexual contact only.  It also spreads if an infected blood syringe or shaving blade is used. The use of infected blood in a transfusion also causes it.”[9] A later report raised the number infected to 48.[10]

Larkhana, 2016

After reports of HIV infection among persons getting dialysis at the Chandka Medical College, Pakistan’s National AIDS Control Program investigated. The investigation found that 56 (27.3%) of 205 dialysis patients were HIV-positive. “The report mentions that infection control practices were few…”[11]

Jalalpur Jattan, 2008

In 2008, an HIV voluntary counseling and testing center near Jalalpur Jattan town in Gujrat noted some unexpected HIV infections. To get a better idea about what was happening, the New Light AIDS Control Society, a local NGO, organized two 1-day HIV-testing camps in the town in June-July 2008. In two days, 246 were tested, and 88 were found to be HIV-positive.[12]

Subsequently, the New Light AIDS Control Society worked with the Canada Pakistan HIV/AIDS Surveillance Project (HASP) and Punjab’s Provincial AIDS Control Program to analyze information from the 88 found HIV-positive in the testing camps plus three found HIV-positive from tests elsewhere. They concluded many infections came from “local medics (quacks) who have not been observing the sterilization and infection control techniques…” Two HIV-positive children had HIV-negative parents, and many women with no sex risk were HIV-positive.[12]

The many HIV infections the New Light AIDS Control Society found got the attention of Pakistan’s National AIDS Control Program in the Ministry of Health. In November 2008, a team from the Ministry made a 1-day visit to Jalalpur Jattan.[13] The report from that visit recommended an investigation. Pakistan’s National Institute of Health assigned Pakistan’s Field Epidemiology & Laboratory Training Program (FELTP) to investigate, with assistance from the US Centers for Disease Control and Prevention (CDC). The terms of reference asked the team (p 263 in [14]) to: “…to determine the extent and chain of transmission” and to “identify…sites of potential transmission.”

FELTP’s resulting report is more of a cover-up than an investigation. (You can find their confidential report here; to protect people with HIV, this link omits family trees on pp 36-48).[15] The investigating team revised and published this confidential report in 2013.[14]

Because it was fairly clear unsafe healthcare was responsible for many infections, at least part of the challenge was to trace and test people who had visited suspected clinics. The team didn’t do that: it didn’t identify any facility suspected to transmit HIV through skin-piercing procedures, and did not invite clients at suspect facilities to come for tests. Instead, beginning with a list of 20 HIV-positive people provided by the local government hospital, the team traced relatives and looked for people with stigmatized behaviors (sex work, male-male sex, injection drug use). Overall, the team identified only 53 persons with HIV, including 26 previously tested.[15]

Even so, the “investigation” did not completely avoid the obvious. The 53 cases included more women than men as well as 6 children aged 1-10 years. The team identified various blood exposures in HIV-positive persons (pp 264-265 in [14]): “The most common risk factor for HIV infection was the history of injections (n = 51, 96.2%)… Twenty seven (96.4%) female patients had a history of ear and nose piercing… Twenty-one (40%) of the cases interviewed had a history of dental procedures… Eighteen (72%) of the men had a history of barber shop visits on a monthly or even more frequent basis… Fourteen (26.5%) gave a history of undergoing a surgical procedure… Eight (15%) had a history of receiving a blood transfusion..”

2021 published review of nosocomial HIV outbreaks in Pakistan

In early 2021, a CDC-managed journal, Emerging Infectious Diseases (EID) published a review of HIV outbreaks in Pakistan.[16] The review found information in medical journals for four nosocomial outbreaks listed on this page (Ratodero, Kot Imrana, Larkhana, and Jalalpur Jattan). In addition, the review (a) attributed an outbreak in Faisalabad to both injection drug use and unsafe health care; because information is not sufficient to say health care was a major factor in the outbreaks, I do not list it here; (b) cites newspaper reports of an outbreak in Chiniot, which I list above; and (c) cites newspaper reports of a possible outbreak in Hyderabad,[17] which I do not list because there is too little information. Overall, it’s good to see confirmation of what we have here!

References

1. Rabbani S. HBV HCV, HIV these blood borne viruses are a three headed monster. No date. Available at: https://dontgetstuck.files.wordpress.com/2012/02/pakistan-three-headed-monster-looming-aids-threat.pdf.1.

1a. Rabold EM, Ali H, Fernandez D, et al. Systematic review of reported HIV outbreaks, Pakistan, 2000-2019. Emerg Infect Dis. 202: 1039–1047. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007288/ (accessed 5 May 2023).

2. Ouyang H. The City Losing Its Children to H.I.V. New York Times Magazine 2 April 2021. Available at: https://www.nytimes.com/2021/03/31/magazine/pakistan-hiv.html (accessed 8 April 2021).

2a. Ahmed T. Ratodero HIV stats continue to rise 19 months after outbreak. Samaa 1 December 2020. Available at: https://www.samaa.tv/news/2020/12/ratodero-hiv-stats-continue-to-rise-19-months-after-outbreak/ (acessed 12 December 2020). See also: Dawoodpoto J. Number of HIV cases in Ratodero rises to 1,204. Daily Times 9 December 2019. Available at: https://dailytimes.com.pk/516543/number-of-hiv-cases-in-ratodero-rises-to-1204/ (accessed 12 December 2019).

2b. Bhatti MW. Dozens getting HIV positive on weekly basis in four Sindh talukas. Geo News [internet] 7 March 2023. Available at: https://www.geo.tv/latest/474811-hiv-outbreak-peaks-in-sindh-as-more-and-more-children-test-positive (accessed 4 May 2023).

3a. Farmer B. Two years after Pakistan’s HIV outbreak, families of infected children are bereaved and shunned. The Telegraph 1 October 2021. Available at: https://www.telegraph.co.uk/global-health/science-and-disease/two-years-pakistans-hiv-outbreak-families-infected-children/ (accessed 26 May 2022). 

3b. Protest against unavailability of health facilities. The Nation 18 April 2022. Available at: https://nation.com.pk/2022/04/18/protest-against-unavailability-of-health-facilities/ (accessed 29 May 2022).

3c. 56 more tested HIV-positive in Sindh’s Ratodero. Available at: https://nation.com.pk/12-May-2019/56-more-tested-hiv-positive-in-sindh-s-ratodero (accessed 15 May 2019).

4. Wahid B. An update on the severe outbreak of HIV in Kot Imrana, Pakistan. Lancet Infect Dis 2019; 19: 241. Available at: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(19)30038-6/fulltext?rss=yes (accessed 4 March 2019).

5. HIV, AIDS outbreak alarms residents. Pakistan Observer, 2 March 2018. Available at: https://pakobserver.net/hiv-aids-outbreak-alarms-residents/ (accessed 13 October 2018).

6.  204 patients test positive for HIV/AIDS in Sarghoda. Dunya News, 19 March 2018. Available at: https://dunyanews.tv/en/Pakistan/431865-patients-test-positive-HIV/AIDS-Sargodha (accessed 4 April 2018).

7. 100 more people tested positive for HIV/AIDS: report. Monitoring report, 16 March 2018. Available at: https://www.pakistantoday.com.pk/2018/03/16/100-more-people-tested-positive-for-hivaids-report/ (accessed 13 October 2018).

8. Zaid M. Afzal MS. HIV outbreak in Pakistan. Lancet Infect Dis 2018; 18: 601. Available at: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30281-0/fulltext
(accessed 4 March 2019).

9. Islam S. AIDS scare in a Chiniot village as 42 residents test positive for HIV. The Express Tribute, 31 July 20178. Available at: https://tribune.com.pk/story/1470850/aids-scare-chiniot-village-42-residents-test-positive-hiv/ (accessed 4 April 2018).

10. 48 people including children diagnosed with AIDS in Chiniot. Daily Dunya 16 September 2017. Available at: http://dunyanews.tv/en/Pakistan/405397-48-people-including-children-diagnosed-with-AIDS-in-Chiniot (accessed 13 October 2018).

11. Altaf A, Pasha S, Vermund SH, Shah SA. A second major HIV outbreak in Larkana, Pakistan. J Pak Med Assoc 2016; 66: 1510-1511. Available at: http://jpma.org.pk/full_article_text.php?article_id=7991 (accessed 4 April 2018).

12. Emmanuel F. Outbreak investigation: Mohalla JogiPura, Jalal Pur Jatan, Distt Gujrat, Punjab. no date. Available at: https://dontgetstuck.files.wordpress.com/2012/01/new-lights-hiv-outbreak-investigation-gujrat-pakistan.pdf.

13.. National AIDS Control Program, Ministry of Health, Islamabad. Report on rapid situation analysis of the HIV outbreak in Jalal Pur Jattan, Gujrat District. November 2008. Available at: https://dontgetstuck.files.wordpress.com/2012/02/natlaidscontrolprogramjpjvisit.pdf.

14. Ansare JA, Salman M, Safdar RM et al. HIV/AIDS outbreak investigation in Jalalpur Jattan (JPJ), Gujrat, Pakistan. J Epidemiol Glob Health 2013; 3: 261-268. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24206797 (accessed 15 March 2019).

15. Field Epidemiology & Laboratory Training Program, National Institute of Health, Ministry of Health, Islamabad. Report on HIV/AIDS outbreak investigation at Jalalpur Jattan, Gujrat, June 2009. Available at: https://dontgetstuck.files.wordpress.com/2012/02/feltp-investigation.pdf.

16. Rabold EM, Ali H, Fernandez D, Knuth M, et al. Systematic Review of Reported HIV Outbreaks, Pakistan, 2000–2019. Emerg Infect Dis 2021; 27:1039-1047. Available at: https://dx.doi.org/10.3201/eid2704.204205 (accessed 22 March 2021).

17. Khan MH. Surfacing of 140 HIV positive cases early this year in Hyderabad goes unnoticed. Dawn 3 May 2019. Available at: https://www.dawn.com/news/1479843 (accessed 7 April 2021).