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Impact of COVID-19 Pandemic in Response to Global HIV Infection,
with Focus on Pakistan

By Mahnoor Sukaina

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Citation

Sukaina M. Impact of COVID-19 pandemic in response to global hiv infection, with focus on Pakistan​. HPHR. 2021;48.  

Impact of COVID-19 Pandemic in Response to Global HIV Infection, with Focus on Pakistan

Abstract

The global burden of the COVID-19 pandemic has exhausted the funds that were initially planned by World Health Organization for the diagnosis, treatment, wellbeing, and awareness for people living with HIV. The target set by UNAIDS 2014 to achieve the 90-90-90 goal by 2020 did not meet and was revised to 95-95-95 by 2025 with the sustainable development goal-3 benchmark of 2030 remains on the target. Amid this COVID-19 pandemic, the HIV treatment goal set by WHO for Pakistan got affected. The economic crisis, strict lockdowns, furloughs, layoffs, feeble healthcare system, the agricultural impact of COVID-19, have affected the progress of HIV goals in Pakistan. While only 23% of HIV-infected patients in Pakistan are aware of their status, 77% unaware of their status are at serious health risk, and pose a risk to the general population.

 

This paper deals with the serious health situation amid the ongoing syndemic; when two or more epidemics are present at the same time. It defines the HIV, its types and strains, and its origins and the global response to tackle the epidemic. It also discusses the point prevalence on the historical situation of HIV in Pakistan, along with its incidence, prevalence and epidemiology of the disease. The paper discusses various global organizations that deal with the plan to treat and eradicate HIV globally and the efforts made by these organizations, and the challenges faced by them due to COVID-19. Furthermore, the impact of COVID-19 in providing the treatment of HIV in Pakistan is discussed, along with some of very important recommendations at the end of this paper.

Introduction

The world is currently witnessing a syndemic; which is two or more epidemics occurring at the same time, thereby, increasing the burden of the disease in the population (Shiau et al., 2020); COVID-19 and HIV. Human Immunodeficiency Virus (HIV) belongs to lentivirus, which may enter the human body through blood, semen, or breastmilk. After entering the body, HIV may alter the DNA of the host cells and attack the immune system by infecting CD4+, macrophages, and dendritic cells (Yousaf et al., 2011). There are two types of HIV virus, HIV-1, and HIV-2, though HIV-2 is a rare virus and is mostly found in West African countries. The origin of HIV is closely related to the Simian Immunodeficiency Virus (SIV) found in chimpanzees (Sharp & Hahn, 2010). Although there are four main groups of HIV strain; M, N, O, and P (Yousaf et al., 2011). It is mainly subtype-M which is identical to the SIVcpz strain that accounts for most of the global HIV infection in humans, which originated in 1931 (Hillis, 2000). HIV-1 is the leading cause of acquired immunodeficiency syndrome (AIDS) (Sharp & Hahn, 2010).

 

While in the 1970s, cases of HIV/AIDS were documented around the world, it was 1986-1987 when HIV was declared epidemic (Mann, 1987). In 1996, the Joint United Nations Programme on HIV/AIDS (UNAIDS) was established and since then UNAIDS is working relentlessly towards eradicating HIV. World Health Organization (WHO), International AID Society, Global Fund, and Kaiser Family Foundation are some of the other global organizations that provide awareness to the populations across the globe regarding the medium through which HIV transmits and possible prevention methods.

Global HIV Eradication Plan

In September 2015, the United States General Assembly proposed an agenda to eradicate the HIV epidemic by 2030 through the establishment of Sustainable Development Goals 3 (SDG-3), which is one of the 17 SDGs proposed by the United Nations(Assefa & Gilks, 2020; Good health and well-being, n.d.).The theme of SDG-3 agenda revolves around the wellbeing of the global population by mitigation of infectious diseases and improvement of health strategies by 2030(Assefa & Gilks, 2020). UNAIDS developed a program in 2014 that focused on the fast-track eradication of AIDS/HIV epidemic by 2030, in which it had a benchmark of 90-90-90 to be achieved by 2020(UNAIDS, 2016; Bain et al., 2017). This is specified as 90% of the global HIV population will be diagnosed with HIV infection, then those 90% HIV diagnosed individuals will get drug regime of antiretroviral therapy (ART), thus resulting in viral suppression of those 90% identified individuals receiving drugs for HIV (UNAIDS, 2016; Bain et al., 2017). However, UNAIDS could not achieve the 2020 targets, partly because of the COVID-19 pandemic, therefore, the 2020 targets are replaced by 2025 AIDS targets.

2020 AIDS Targets: Why Did They Not Work?

According to UNAIDS 1.5 million people globally became newly infected from HIV in 2020, while the COVID-19 pandemic alone will account for an estimated 123,000 to 293,000 HIV cases and an additional 69,000 to 148,000 AIDS caused deaths (UNAIDS, 2020a).

 

Worldwide lockdowns have dramatically affected the delivery of HIV care due to disruption in the supply chain, limited capacity to accommodate patients to maintain social distancing, and diversion of healthcare resources to COVID-19 care. In addition to the current scenario, another challenge that impedes the progress of sustainable development goals is the spread of myths and false information in the COVID-19 pandemic through fake news and social media by preventing factual information delivery to the general public (Seshaiyer & McNeely, 2020). This hampers effectiveness and decision-making among governing bodies regarding the dissemination of correct and verifiable information (Seshaiyer & McNeely, 2020).

 

However, research by Levi et al. (2016) argued that the 90-90-90 goals are unlikely to be achieved by all the countries around the world. Levi et al. (2016) found a wide spectrum in achieving the targets. The first target of 90% people will be diagnosed, ranging between 87% by the Netherland to 11% by Yemen. The second target of 90% of those diagnosed with HIV infection will get ART, ranging between 71% by Switzerland to 3% by Afghanistan. Finally, the third target of 90% viral load suppression amongst 90% individuals on ART, ranged between 68% in Switzerland to 7% in China.

2025 AIDS Target

The 2020 AIDS target is replaced with the 2025 AIDS target, with the revision of the 90-90-90 benchmark to 95-95-95. 95% of the global HIV population will be diagnosed with HIV infection, then those 95% HIV diagnosed individuals will get ART, thus resulting in viral suppression of those 95% identified individuals on the ART (UNAIDS, 2020a). In addition to the revision of 90-90-90 targets, UNAIDS aims to achieve two additional 95% targets; which is, 95% of the women will get HIV, sexual and reproductive health services, and 95% elimination of vertical transmission (UNAIDS, 2020a). 

 

UNAIDS also targets to achieve less than 10% of the countries will have punitive laws and policies towards HIV-infected people while increasing the awareness to reduce the discrimination faced by HIV-infected people. Less than 10% of individuals will face discrimination in health facilities, negative behavior, and stigmatization in social terms. Less than 10% of individuals will face inequity, gender biases, and physical and sexual violence among the vulnerable population, particularly in women and homosexuals (UNAIDS, 2020a).

Integration

In order to achieve the 2025 AIDS targets, UNAIDS has redesigned its approach that places people living with HIV (PLHIV) at the center of providing integrated service that makes it convenient for the patients to receive ART. Rather than providing service based on the infrastructure and resource allocation of the dispensing facility, the integration provides customized and tailored health service that primarily targets four dimensions; efficiency, effectiveness, equity, and responsiveness (UNAIDS, 2020a).  The theme focuses on multiple agendas, all revolving around the wellbeing of the people at high risk of HIV infection. This covers the topic of universal health coverage (UHC), and the access to it by people who cannot either afford or the health service availability is a concern (UNAIDS, 2020a).  It also targets migrant communities around the world and uses a subjective approach for all to decide the rendering of service integration that prioritizes infected people’s health or those at great exposure (UNAIDS, 2020a).

Condition of HIV Infection in Pakistan

Historical Situation of HIV in Pakistan

The first case of HIV/AIDS was reported in 1986 in Pakistan (Bhurgri, 2006; Emmanuel et al. 2013)). Later in 1990, the first government response to address HIV/AIDs was developed with the support of the World Health Organization (WHO), which in 1993 extended it to the National AIDS Control Program (NACP) (Bhurgri, 2006). In 1999, NACP extended collaboration and jointly started working with UNAIDS to tackle the HIV epidemic (Bhurgri, 2006). Pakistan witnessed its first HIV outbreak in 2003 in incarcerated injection drug users (IDUs) in Larkana (Khan & Khan, 2010). The second outbreak was reported in patients receiving dialysis in 2016 in Chandka Medical College in Larkana (Altaf et al., 2016). The third outbreak was reported in 2018 in Kot Imrana (Kot Momin) in Sargodha when 5000 people were found to be HIV positive (Wahid, 2019). The fourth HIV outbreak was also reported in 2019 in Rato Dero, Larkana of which the majority are pediatric patients receiving a blood transfusion or the reuse of non-sterile syringes (Mir et al., 2020; Arif, 2019). Although there were reports of an early outbreak in 2008-2009 in Jalalpur Jattan in Gujarat that found 88 out of 246 people tested for HIV rapid test to be positive, the investigation was halted for further inquiries (Ansari et al., 2013).

Incidence and Prevalence of HIV in Pakistan

Pakistan is among the four Asian countries where the rate of HIV infection is rising (Mir et al., 2019; The Express Tribune, 2020), while only 23% of the overall population suffering from HIV infection in Pakistan are aware of their status (Ouyang, 2021). 45% cases were increased from 2010 till 2017 with the statistics of 20,000 cases each year (Arif, 2019). In 2018, there were 22,000 documented cases of new HIV infection, as compared to 14,000 in 2010, with an exponential increase in death due to HIV infection (Siddiqui et al., 2020; Ouyang, 2021). Although the prevalence of HIV infection in the Pakistani general population is less than 0.1% with 165,000 PLHIV as of June 2019 (Ali et al., 2019), Pakistan is the second-fastest-growing country in Asia in terms of HIV infection (Ali & Ali, 2020).

Epidemiology of HIV infection in Pakistan

In understanding the incidence and prevalence of HIV infection among the Pakistani population, the paper categorizes the occurrence and prevalence through four broader groups.

Sex Workers and Injection Drug Users

Early evidence of HIV infection was found among seafarers and migrants especially from Gulf countries, who were deported because of their HIV infection abroad (Khawaja et al., 1997). Since these migrant workers remained far from their families often fifty to fifty-one weeks per year, there were reports of these workers having multiple sex partners (Khawaja et al., 1997). Similar instances of casual sex partners are found in bus and truck drivers, who are involved in casual sex with female sex workers (FSWs), transgender sex workers (TSWs) called hijra (Khawaja et al., 1997), or homosexual or bisexual men (Khanani et al., 2011). These truck drivers are often involved in sexual activities with young boys who accompany these drivers as helpers or cleaners (Khawaja et al., 1997). The transmission of HIV infection is faster through anal intercourse as compared to the vaginal (Khanani et al., 2011). According to a study by Emmanuel et al. (2010), FSWs formed the largest group of HIV-infected individuals, followed by IDUs, followed by male sex workers (MSWs) and TSWs. Combined MSWs and TSWs equal or exceeds the population of FSWs, and this is alarming in all Pakistani cities (Khan & Khan, 2010). A later study by Emmanuel et al. (2013) found an increasing number of IDUs and a well-established sex work industry in all Pakistani cities. Although sex workers remain the critical driver in the transmission of HIV infection worldwide, their role in Pakistan remains understudied, as the total documented population of the sex workers remains 3 million which is relatively small compared to the general population of over 225 million (Khan & Khan, 2010). Khanani et al. (2011) discussed the similar bridging pattern of transmission from the core group to the general population was found in Eastern Europe, Russian Federation, and Central Asia where HIV infection initially found in IDUs was transferred to men who have sex with men (MSM) to the bisexual men to their spouses and offspring.

Non-sterile Blades and Injections

As the recent 2019 HIV outbreak in Larkana suggests the usage of non-sterile therapeutic syringes and pieces of equipment are the critical drivers of the transmission of HIV infection especially in the rural areas, where on average people are given over 10 injections per year by the general practitioners (Emmanuel et al.,2013; Khan & Khan, 2010). Khan and Khan (2010) found that approximately half of the IDUs and sex workers are married, and spouses of IDUs were found to inject diazepam by the local providers. Therefore, this category remains a crucial linkage in the transmission of the infection to the general population. Reusability of disposable syringes multiple times on different patients is one of the leading causes contributing to the spread of HIV infection in the country (Ali et al., 2017; (Khawaja et al., 1997). 94% of syringes in Pakistan are reused due to unavailability of resources in small villages called Qasbas, corrupt government management, and medical staff including negligent or unqualified nurses and doctors that leave needles uncapped and exposed (Ali et al., 2017).

 

Another understudied and underestimated driver of transmission of HIV infection in Pakistan is the street barbers that use non-sterilized blades for shaving and haircutting. Street barbers are not even posed as the threat in the poor and illiterate population for the transmission of the HIV infection (Krishanani et al., 2014). These street barbers often use the non-sterile blades in male circumcision (Ali et al., 2019). Similarly, street-based teeth extractors use non-sterilized equipment in carrying out dental procedures (Khan & Khan, 2010).

Blood Transfusion

Akhtar et al. (2020) discussed that β-thalassemia is the foremost inherited blood disorder in Pakistan, with a carrier of 5% -7% of the Pakistani population. Bloodborne disease is the second frequent cause of mortality in these patients (Akhtar et al., 2020). Khan and Khan (2010) found that over 1.5 million units of blood are transfused annually in Pakistan, with two-third in the public sector and government hospitals. Further, 20%-40% of the blood remains unchecked for any communicable disease (Khan & Khan, 2010). Although there is a law of mandatory screening of the blood before the transfusion, it remains unenforced (Khan & Khan, 2010).

Parent to Child Transmission

Khan (2017) discussed that HIV infection can be transmitted by the mother to her unborn child during pregnancy, birth, and breastfeeding, and accounts for over 90% of preventable new HIV infections in Pakistan by giving ART to HIV-positive pregnant mothers. Another under-researched topic is the transmission of HIV infection by HIV-positive maids or midwives, who could be the wives of IDUs to neonates during breastfeeding. Khanani et al. (2011) discussed the increase of transmission of HIV infection to the offspring of bisexual men who have sex with men (MSM).

Impact of COVID-19 on HIV Eradication Plan

WHO declared SARS-CoV-2 as a pandemic in March 2020, and since then it has disrupted the world economy due to lockdowns, therefore, rigorously diverting and exhausting the global funds in breaking the COVID-19 chain. As of mid-August 2021, there are over 207 million cases of COVID-19 infection, while the death toll has surpassed 4.3 million worldwide (Worldometers, 2021). McKinsey & Company (2021) estimates the financial impact of COVID-19 on the world economy would range between $16 trillion to $35 trillion by 2025. According to April 2021 The Global Funds report, the health services for HIV have largely been interrupted by the pandemic in low-income and middle-income countries of Asia and Africa. HIV testing dropped to 41% from April to September 2020 as compared to the same period in 2019.

 

A study by Hogan et al. (2020) illustrates that disruptive management of HIV can potentially increase the mortality rate to 10% due to the rise in the COVID-19 pandemic, challenges such as lack of staff due to increase workload, and coinfection making the infected people susceptible to other diseases (Hogan, et al., 2020). A study by Bhaskaran et al. (2021) in English and South African population suggested that PLHIV are vulnerable to higher COVID-19 related morbidity and deaths, while parameters including other comorbidities, viral load, CD4 count and ART plays a vital contribution.

 

The clinical correlation of COVID-19 and HIV is complexed. A low CD4 count in HIV patients may restrict the cytokine storm induced by COVID-19, thus preventing the severity of complications in HIV patients (Nagarakanti et al., 2020). However, the poorly development IgM with CD count less than 200 in HIV patients can worsen the COVID-19 disease progression. The co-infection severity and mortality is required to be further investigated, as limited data is available to conclude the relationship (Cooper et al., 2020). A systemic review of co infection suggest that PLHIV and COVID-19 does not pose serious health risk if the if the patient is virally suppressed by ART. However, sero-positive patients and poor prognosis of HIV and COVID-19 is unclear and needs to be further researched (Cooper et al., 2020).

 

 Two separate research also found that PLHIV are more prone to contract SARS-CoV-2 infection due to immunocompromised health status (Waterfield et al., 2021; Lee et al., 2021). Their risk of mortality perhaps increases especially in the African population, especially in individuals with systemic comorbidities such as fever, heart diseases, diabetes mellitus, pulmonary infections, hypertension, and cancer (Waterfield et al., 2021; Lee et al., 2021).

 

The situation of PLHIV remains alarming in LMICs, where a survey by Khan et al. (2021) found 40% of respondents found it severely challenging to access healthcare facilities due to fear of getting infected with COVID-19, strict lockdowns, and disruptive transport. The providers and frontline workers in the healthcare sector found it onerous to reach healthcare facilities due to disruptive transport (Khan et al., 2021).

Impact of COVID-19 on PLHIV in Pakistan

Challenges Faced During HIV Outbreak

Challenges Faced During HIV Outbreak

 In 2020, complete or partial lockdown to foster self-quarantine was the foremost strategy adopted by the government across the world to tackle the spreading of novel SARS-Cov-2 infection to the masses. While in Pakistan, especially in the province of Sind, the partial lockdown started in early March 2020, followed by the complete lockdown, therefore, making it infeasible to seek healthcare (Khan et al., 2021). A substantial number of daily wagers including waiters, drivers, skilled and unskilled workers, and housemaids were furloughed or got layoff. Either due to the fear of getting infected or simply the owners of the businesses could not afford to pay salaries to the workers as their businesses were closed due to the lockdown.

 

At one end, the stringent financial conditions and scarce resources made it difficult for the daily wagers to meet their expenses for daily living (Ahmed et al., 2020), especially in Pakistan that is not a welfare country. On the other hand, non-COVID-19 cases lost their importance in getting healthcare priorities. Funds were diverted to respond to the COVID-19 emergency, therefore resulting in lesser priority, especially towards the response to HIV infection (Dawn, 2020; Khan et al., 2021). Due to COVID-19, the cost of essential items for the general population especially in the high-income countries but unaffordable for the poorer segments of low and middle-income countries including face masks, hand sanitizers, and disinfectants exhausted the already limited budgets in healthcare facilities, particularly in rural towns and villages (Ahmed et al., 2020).

Challenges Faced During HIV Outbreak

There is a huge socioeconomic disparity and lack of awareness to encounter prevention for HIV. According to the GINI index, in 2018, the poverty rate in Pakistan was 31.6% (Gini Index, n.d.), while 75.6% population lives on earning less than $5.50 per day (Pakistan Poverty Rate 1987-2021, n.d.), and literacy rate in Pakistan was documented to be 59.1% in 2017 (O’Neill, 2021). Regardless of securing top ranking in agricultural produces in the world for several important commodities, 36.9% of the population does not have sufficient food resources available (Rasheed et al., 2021). All non-essential businesses closed during the lockdown deteriorated the economic condition of the country at the macro and micro levels (Rasheed et al., 2021). Pakistan has made continuous efforts to decline the poverty ratio across the country. COVID-19 has hindered the efforts to reduce poverty across Pakistan by enforcement of strict lockdown, affecting the travel, agricultural, and oil industry, which eventually contributes towards the decline in the economy.

 

Unemployment has led to economic recession nationwide; millions of Pakistanis lost their jobs amid pandemic with the rate of unemployment of labor workforce reaching 4.7 in 2020 as compared to 3.98 in 2019 (UNDP, 2020; ILOSTAT, 2021). Marital rape, unwanted pregnancies, and unsafe abortion increased due to the COVID-19 pandemic (Shah et al., 2021), therefore, further posing a threat to the post-COVID increase in HIV infection in Pakistan.

 

Moreover, pre-COVID-19 local pharmacists play a vital role in dispensing medicine for minor illnesses, which became further imperative during the COVID-19 in low and middle-income countries (Ahmed et al., 2020).  The testing, screening, treatment, and therapy especially for the HIV infection decreased due to the fear of catching the COVID-19 virus (Ahmed et al., 2020). WHO supported new incinerators for safe disposal of syringes but enforcement paused due to the COVID-19 pandemic (Ouyang, 2021). A study demonstrated that the prevalence of HIV in Pakistan is also associated with 2.63% of Afghan refugees, a ratio of 55% of male immigrants in Pakistan who practice unprotected intercourse (Ali et al., 2017).

 

There is a high prevalence of HIV infection amongst the transgender community of Pakistan due to gender discrimination and stigma (Akhtar et al., 2012). Prior 2018, transgenders were not provided with the national identity card (NIC) and were not included in the national database and registration authority (NADRA) (Hussain, 2018). The transgender community is the most neglected community in Pakistan, and they are left with no other choice to either beg on the streets or work as sex workers or dancers (Haider, 2017). Moreover, lack of education, unemployment, and poverty has darkened their prospects to enjoy an average life as others do in Pakistan (Akhtar et al., 2012). There is a lack of data on the religious preferences of the transgender community in Pakistan, but overall, as an Islamic country, a major proportion of the transgenders are Muslims, but they are not provided with the visa for Saudi Arab to perform mandatory and preferential pilgrimage (Hussain, 2018).

Effects on Reproductive Health and ART Availability

Women’s reproductive health and neonatal heath risk rise exponentially in the COVID-19 pandemic era (Shah et al., 2021; SickKids & UNICEF, 2021). The United States Sustainable Development Group (UNSDG) released the COVID-19 Pakistan Socio-economic Framework on May 14, 2021. According to this report, it is expected that the chances of unintended pregnancies will increase in pandemic due to the anticipating shortage of contraception including 500,000 oral contraceptive pills, 672,000 intrauterine devices, and 800,000 injectable progestin. Perhaps it can increase the proportion of postpartum infection, the neonatal transmission of HIV infection, and termination of unwanted pregnancies by an unskilled person in unsterilized areas due to inaccessible medical care in lockdown. Furthermore, the estimated depletion of 3 million condoms across the country will expand the possibility of HIV transmission among the public and the unavailability of Antiretroviral Therapy will rise the HIV burden nationwide (UNSDG, 2020).

Efforts Made by Governing Bodies

Continuing the service delivery for HIV in Pakistan is challenging yet important to maintain public health suffering from a communicable disease like AIDS. NACP in collaboration with the UNAIDS and Association of People Living with HIV (APLHIV) has successfully established 50 ART centers nationwide in Pakistan (Pakistan National AIDS Control Programme, n.d.). Furthermore, these governing bodies have created an Emergency Response Cell (ERC) to provide immediate response for HIV curbing-related services (UNAIDS, 2020b). HIV mitigation service included door service delivery of ART by NACP through APLHIV and Provisional Aids Control Programme, by creating a prioritizing criterion according to three groups (UNAIDS, 2020b). The red group includes people with less than 14 days of supply of ART doses, a yellow group for patients who have ART stock for a month, and more than a month of supplies are included in group green (UNAIDS, 2020b).

 

Besides food and nutrition supply for 3200 people, APLHIV made prompt enforcement to support 4000 HIV patients enrolled in the government programs in Pakistan. The aim is to provide relief for them during COVID-19 pandemic and continuation of support to the patients through ERC until the covid-19 cease to exist (UNAIDS, 2020b).

 

Moreover, the Global Funds has supported Pakistan in preventing the HIV epidemic and helped in the continuation of access to ART to PLWHIV via monetary aid. The Global Funds have signed for USD 22,241,128 for grants to the Ministry of National Health Services, Regulations and Coordination of Pakistan from 2013 to 2021, out of which USD 18,707,208 is allocated for the prevention, screening, diagnostics, and treatment of PLHIV. Despite the disposal of USD 697 million in grants to Pakistan to fight against the HIV epidemic in the country, only 23% of the HIV infected population are aware of their status and only 13% are on the treatment (Global Fund Grants in the Islamic Republic of Pakistan, 2020).   USD 22,500,430 has been allocated from 2013 till 2023 to the Nai Zindagi; an organization working in Pakistan to provide care to PLHIV and eradicate the infection nationwide. Nonetheless, strict audit policies and predefined guidelines should be implemented by the governing bodies to monitor the dispensing of the funds.

Recommendations

Pocket Targeting and Testing

Pakistan is a densely populated country, and dividing PLHIV into small clusters and pockets makes it easier for relief work. Transgenders, beggars, drug users, and sex workers have their allotted areas, and they work as a gang, operated by the mafia. Seldom an individual who does not belong to these groups can operate in their areas. Rigorous and repeated testing should be done in these clusters, and if anyone is identified with HIV infection, then their contacts should be tested to confirm the presence of the HIV.

Curbing Unsterilized Practices in Barbers and Street-based Teeth Extractors

Safe and sterilized practices especially in the under-researched category of barbers and street-based teeth extractors should be given the highest priority by asking them to dispose of the blades after usage. Strict measures should be made to implement policies for the usage of safe and disposable syringes. Weekly audits should be done to ensure that these practices are in place. Otherwise, only counseling will not be of much benefit in this segment of the population. Violators of not following the safe practice of using the sterilized equipment should be fined. Punitive measures would be needed to curb their unsafe practice of reusing blades for shaving, haircutting, and male circumcision, as they can be the bridging point for the prevalence of HIV to the general population. 

Recruiting Among the Clusters

Poverty and unemployment are some of the foremost causes of people indulge in drugs and sell sex in the poorer nations. In 2017, the first passport was issued to a transgender in Pakistan. In 2018, the court ruled that transgenders can have an identity. This means, that prior to 2017, transgenders did not have an identity and they were not included in NADRA. There is an extremely strong disparity in providing employability to transgenders in Pakistan. Neither public nor private institution has a presence of transgender in terms of workforce. Similarly, education in the transgender community is minimal.

 

Therefore, providing employment opportunities to transgenders and IDUs will be of ample help to the government’s drive to eradicate HIV infection from Pakistan. Firstly, these individuals will help to identify their peers. Secondly, efforts will be made to eradicate poverty in these clusters by providing employment opportunities. Few generations will be required to fully amalgamate the transgenders into normal Pakistani society, nevertheless, the sooner the better.

Private Companies Allocation

The Corruption Perceptions Index ranks Pakistan at 124th number out of 180, which means that corruption is very high in the country. The corruption in the public sector is greater than in the private sector, primarily because of a lack of governance and surveillance. The official salary given to the lower and middle-level staff in the public sector is far less than the private sector. A significant proportion of government employees comes from rural areas; therefore, political influence is at large. Although NGOs are working in the areas that keep a check and balance upon the government practices, there is limited research on the credibility of their checks. On the contrary, if the disbursement of funds to help PLHIV be provided to private companies, it will have lesser chances of corruption as compared to the government.

Substance Abuse and Dependence Program

In Karachi, mostly IDUs are found in areas near railway stations, or older bridges. The majority of them live as homeless, and they are involved in stealing mostly iron in the form of manhole covers, or iron rods from the concrete slabs that are used to cover open sewer drains, or drain grates. They sell iron to buy drugs and inject in a group of four to six people, often sharing needles. Even if they are caught by police, after spending few nights in jail, they are voluntarily released, often in an exchange for money or drugs. Efforts should be made to start them on outpatient therapy rather than rehab centers. Medications such as buprenorphine in combination with naloxone should be provided in sublingual films, hence it will have the ceiling effect, and at the same time, these addicts will not be able to crush and inject them with it.

Helpline for Youth

The young boys who accompany the truck drivers and long route bus drivers are the victims. Usually, these boys do not go to school mostly due to the financial conditions of the family. The drivers pay a very small amount to the parents and convince them that these boys will get used to the roads and highways. Once they are on the route, these drivers either sexually assault these boys or some of the boys are so naive that they do not know the sexual practices. After they have been sexually assaulted, they either do not report due to the shame or due to the fear of being killed. Therefore, a mechanism should be made and implemented so these boys do not fall victim to these drivers.

 

One of the methods is auditing the bus and truck stands and questioning these young boys. Another method is these busses and trucks pass via different checkpoints on the highway, routine stops and quick questioning should be done to keep track of the drivers and the young boys. Thirdly, electronic bracelets with SOS buttons with geo-tracking should be provided to the young boys in slums, and Islamic schools called madrassah, which these boys can use whenever in danger. The SOS button can give the signal to the Helpline for Young, which should take prompt action.

Medication Database

NACP operates 50 ART centers nationwide. A database for the medication regimen for all the registered patients should be made and maintained to follow up on PLHIV. In general, people in Pakistan visit a doctor only when they are sick. The concept of maintenance therapy is still in the early stages among the general population. After the successful implementation of the medication database in PLHIV, the medication database should be extended to other chronic conditions. This will decrease the burden of healthcare on the government in the long term. The idea of a medication database is a similar concept to that of the Prescription Drug Monitoring Program (PDMP), which is already implemented and in usage in the United States but with two significant differences. First, PDMP in the US keeps track of controlled substances, secondly, it does not focus on replenishing the drugs. On the contrary, the medication database would dispatch the medications through the postal service when the patients would be due for the medications.

Conclusion

HIV infection has risen by 74% in Pakistan, and amid the COVID-19 pandemic, the progress upon the goals set by SDG-3 did not meet the benchmark. The strict measures including lockdowns have worsened the situation, with Pakistan being a low-income country, where, 75.6% percent of the population lives less than earning US$ 5.50 per day. The commonest mode of transportation is public buses, and lockdowns have disrupted the transportation system, therefore, further limiting the HIV-infected people to seek to continue medication regimens. The benchmark set by UNAIDS for 90-90-90 in 2020 was not achieved due to the sudden outbreak of the COVID-19 pandemic, however, while the 2030 target remains focused, a new benchmark of 95-95-95 is set to be achieved by 2035. The scarcity of funds and skilled resources in tackling the HIV epidemic globally and especially in Pakistan has further decelerated the continuing of medication regimens in HIV-infected people. Though the efforts are made and the progress was seen in the plan to eradicate HIV by 2035, the COVID-19 pandemic has slowed the progress, and external force is required to fast-track it.

Acronyms

AIDS: Acquired Immunodeficiency Syndrome

APLHIV: Association of People Living with HIV


ART: Antiretroviral Therapy


ERC: Emergency Response Cell


FSWs: Female Sex Workers


HIV: Human Immunodeficiency Virus


IDUs: Injection Drug Users


LMICs: Low and Middle-Income Countries


MSM: Men who have sex with men


MSWs: Male Sex Workers


NACP: National AIDS Control Program


PLHIV: People Living with HIV


SDGs: Sustainable Development Goals


SIV: Simian Immunodeficiency Virus


TSWs: Transgender Sex Workers


UHC: Universal Health Coverage


UNAIDS: The Joint United Nations Programme on HIV/AIDS


UNDP: United Nations Development Programme


UNICEF: The United Nations Children’s Fund


UNSDG: United Nations Sustainable Development Group


WHO: World Health Organization

References

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About the Author

Sahana Arkalgud

Mahnoor Sukaina is with Karachi Medical and Dental College, in Pakistan. She write, “I am very enthusiastic and ambitious to serve the community through my knowledge, research capabilities and clinical acumen. Currently, I am preparing for USMLE step 1 and foreseeing residency in the U.S.”