Although the estimated HIV burden is still low—around 0.1 percent of the adult population – Pakistan is facing a concentrated epidemic among injecting drug users (IDUs) with HIV prevalence of 21 percent among IDUs in major urban centers across the country. Given linkages between IDUs and other vulnerable populations including male and female sex workers, Pakistan needs to scale up targeted intervention urgently to prevent rapid increase in HIV among vulnerable groups.
State of the Epidemic
According to UNAIDS estimates, about 97,000 people were living with HIV in Pakistan at the end of 2009. Officially reported cases are, however, much lower. As in many countries, underreporting is due mainly to the social stigma attached to HIV, limited surveillance and voluntary counseling and testing systems, and the lack of knowledge among the general population and health practitioners.
Although overall HIV prevalence is low, HIV is well established among IDUs and epidemic is also spreading among transgender (6%) in a few cities. HIV among female sex workers has remained negligible. Given the protective effect of circumcision, a generalized sexually transmitted epidemic is unlikely but evidence of significant linkages between sex work and injecting drug use point to the potential for the spread of the epidemic far beyond these groups.
There are serious risk factors that put Pakistan in danger of facing a rapid spread of HIV if immediate and vigorous action is not taken:
Concentrated Epidemic among Injecting Drug Users: Despite various preventive efforts, infection rates among IDUs have steadily increased from 10.8% in 2005 to 37.8% (95%CI: 37.3%, 38.3%) in 2011. Not only has the overall prevalence increased, but the number of sites with relatively advanced epidemics has also expanded. With the exception of Pakpattan, all 17 cities where the survey was conducted showed prevalence rates of over 5% among IDUs. In cities like Faisalabad, DG Khan, and Gujrat, HIV prevalence was close to 50% among the surveyed population. Also of concern is that on average, the majority of IDUs start injecting in their mid-twenties (25.6 years) and have been injecting for about five years. The frequency of injecting was also high with almost three-quarters of IDUs surveyed (71.5%) reported injecting between two to three times a day in the past month and 21.1% reported injecting more than three times a day. Approximately 90.5% of IDU reported injecting in public spaces and 80.9% reported injecting with friends/family; about and exceptionally high proportion (70.3%) reported that they had sought help in injecting by “professional injectors/street doctors” during the past month. Poly-drug use was the norm with Avil being the drug of choice in most cities except for Rahim Yar Khan, DG Khan, Sargodha, Larkana, and Turbat where heroin was the drug of choice. Safe injection practices are uncommon and trends in injecting with a used needle are not encouraging.
HIV among Male Sex Workers and Transgenders: The overall HIV prevalence among MSWs remains low at 3.1% (95%CI: 2.8,3.4)and concentrated in Karachi (5.9%, 95% CI: 3.9, 8.9) followed by Larkana (3.1%, 95% CI: 1.7, 5.4). No MSW tested positive for HIV in Haripur, Peshawar, and Sargodha and the prevalence in the remaining cities was between 0.3% and 2.2%. While these results may be encouraging, of concern is the almost 3-fold increase in the HIV prevalence among MSWs since 2008. This finding, coupled with the IDU and sexual networks with IDU and HSWs in certain cities suggest that MSWs remain at risk for HIV transmission. MSWs tended to be young; 42.1%were between 13 and 19 years of age. Education levels were low (approximately 40.2% had received no formal education) and more than 80% of MSWs lived at home with their families. However, nearly 11.6% of the MSWs had traveled to other cities within the past year, 3% had travelled internationally and of the latter, 79.2% had travelled for sex work. Overall, only 13% reported regular condom use with commercial sex partners; the proportion was lower (10.9%) with non-commercial sex partners. Younger MSWs less likely to use condoms when compared to older MSWs. With an overall HIV prevalence of 7.2% (95%CI: 6.8%, 7.5%), the HIV epidemic appears to be more established in HSWs than among MSWs and FSWs, though much of this is influenced by very high prevalence among HSWs in Larkana (15%, 95% CI: 11.6, 19.1) and Karachi(12.3%, 95% CI: 9.3, 16.1).
Unsafe Practices among Female Sex Workers: Commercial sex is prevalent in major cities and on truck routes. Behavioral and mapping studies in three large cities found a sex worker population of 200,000 nationwide including 125,000 female sex workers and roughly 35,000 each of male sex workers and transgender. Condom use is still low during commercial sex encounters. Furthermore, sex workers often lack the power to negotiate safe sex or seek treatment for STIs. High levels of sexually transmitted infections indicate widespread sexual risk‐taking. When compared to the other key populations, FSWs had the lowest prevalence of HIV infection. In 2011, a total of 27 FSWs tested HIV-positive, for an overall weighted prevalence of 0.8% (95% confidence interval, 0.4, 0.9). However it is noteworthy that there was only 1 positive HIV case among all FSWs tested in 12 cities during the previous round of IBBS in 2008. Furthermore, in certain cities (Lahore, Multan, Quetta, and Sukkur) the fairly extensive FSW/IDU sexual network suggests a potential for the spread of HIV from IDUs to the FSW population.
Inadequate Blood Transfusion Screening and High Level of Professional Donors: It is estimated that 40 percent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. About 20 percent of the blood transfused comes from professional donors.
Large Numbers of Migrants and Refugees: Large numbers of workers leave their villages to seek work in larger cities, in the armed forces, or on industrial sites. A significant number (around four million) are employed overseas. Away from their homes for extended periods of time, they may be at increased risk for exposure to HIV.
Unsafe Medical Injection Practices: Pakistan has a high rate of medical injections ‐around 4.5 per capita per year. Studies indicate that 94 percent of injections are administered with used injection equipment. Use of unsterilized needles at medical facilities is also widespread. According to WHO estimates, unsafe injections account for 62 percent of Hepatitis B, 84 percent of Hepatitis C, and 3 percent of new HIV cases.
Low Levels of Literacy and Education: Efforts to increase awareness about HIV among the general population are hampered by low literacy levels and cultural influences. In 2006 female literacy was estimated at 42 percent.
Vulnerability Due to Social and Economic Disadvantages: Restrictions on women's and girls’ mobility limits access to information and preventive and support services. Young people are vulnerable to influence by peers, unemployment frustrations, and the availability of drugs. In addition, some groups of young men are especially vulnerable due to the sexual services they provide, notably in the transport sector. Both men and women from impoverished households may be forced into the sex industry for income.
National Response to HIV/AIDS
Government: Pakistan’s Federal Ministry of Health initiated a National AIDS Prevention and Control Program (NACP) in 1987. In its early stages, the program was focused mainly on blood screening and some health promotion and HIV education activities for the general population. It suffered from a weak strategy that did not address high risk populations and inadequate surveillance and research whereby there was little credible data to inform decision making. The National Strategic Framework for HIV AIDS was developed in 2001 through a broad consultative process that set out priorities for effective control of the epidemic. Based on the Framework the Government launched the “Enhanced HIV‐AIDS Control Program” for the period from 2003‐2008. The Program marked a shift to a decentralized approach with the NACP and five provincial Programs that would oversee implementation of most activities.
The Program supported by the Bank financed HIV‐AIDS Prevention Project marked a shift in the focus from screening and general education campaigns to HIV preventive services delivered through NGOs for most at risk populations (MARPS) particularly IDUs and sex workers. A systematic approach was adopted for contracting NGOs. The Government defined outputs, scope of services and geographical areas to be covered and selected NGOs through an open competitive process. A total of 18 service delivery packages (SDPs) were contracted out covering IDUs in 7 cities, MSW/transgender in 6 cities, FSWs in 5 cities, jail inmates in 5 cities and truckers nationwide.
Other components of the Program included: (i) improved HIV prevention by the general population through behavior change and communication and advocacy; (iii) prevention of HIV through safe blood transfusion; (iv) capacity building of the federal and provincial programs and NGOs and care for people living with AIDS. The capacity building component also included second generation HIV surveillance and evaluation that was financed by CIDA. In addition, the Government received assistance from the Global Fund Grant Round 2 for procurement of ARV medicines, training of health providers in ART and establishing VCT centers for the general population.
The Government has approved costed plans for the next five year period of the Program. In moving forward the Program aims to address challenges faced in the first phase including a renewed focus on: i) scaling coverage and quality of interventions for most at risk populations; ii) behavioral and biological surveillance and monitoring and evaluation; iii) adopting a strategic approach to communication and advocacy with a greater emphasis on reducing stigma and discrimination; and iv) strengthening treatment and care.
A draft national AIDS policy and HIV and AIDS Law (both recommending the formation of a National AIDS Council) have been prepared by the National AIDS Control Program and will be presented to the national cabinet and parliament. Approval of the policy and law would be an important step towards the multi‐sectoral dimension of the national response.
With the passage of the 18th amendment the Ministry of Health has been devolved and the provinces are now responsible for implementation of all health related interventions. The overall implementation and financing arrangements are still being clarified while at present the National Aids Control program is functioning as a coordinating center for the provinces and is providing much needed coordination with the international partners and provincial setups.
Non‐Governmental Organizations (NGOs): At least 54 NGOs are involved in HIV/AIDS public awareness and in the care and support of persons living with HIV/AIDS. These NGOs also work on education and prevention interventions targeting sex workers, truck drivers, and other high‐risk groups. NGOs serve as members of the Provincial HIV/AIDS Consortium, which has been set up in all four of Pakistan’s provinces to coordinate HIV/AIDS prevention and control activities. Although NGOs are active in HIV/AIDS prevention activities, it is believed that they are reaching less than fifteen percent of the vulnerable population.
Donors: There is a Theme Group and a Technical Working Group on HIV/AIDS to coordinate the response of United Nations Agencies and to provide assistance to the government in the strategic development of activities. The theme group includes UNAIDS, WHO, UNICEF, UNFPA, UNDP, UNDCP, UNESCO, ILO, the World Bank, national and provincial program managers, and representatives of nongovernmental organizations.
Issues and Challenges: Priority Areas
Vulnerable and High‐risk Groups
-Expand knowledge, access, and coverage of vulnerable populations—particularly in large cities—to a package of high impact services, through combined efforts of the government and NGOs.
-Implement harm‐reduction initiatives for IDUs and safe sex practices for sex workers. Make effective and affordable STI services available for MARPs.
Communication and Advocacy
-Undertake a communication campaign focusing on the following objectives: (i) promote tolerant and caring behaviors towards people living with HIV and members of vulnerable populations; ii) provide complete and correct knowledge of HIV transmission and prevention.
-The objective of advocacy would be to improve the environment for HIV prevention by reducing barriers to program acceptance and effectiveness specifically to lift barriers for effective interventions for high risk populations.
Surveillance and Research
-Strengthen and expand the behavioral and biological surveillance to inform programming and monitor outcomes. and monitoring system
-Operationalize a comprehensive monitoring and evaluation framework that will include strengthening MIS, external assessments of performance, capacity building and utilization of data
Building Management Capacity
-Continue to build management capacity within provincial programs and local NGOs to ensure evidence‐based program implementation.
-Identify gaps in existing programs and continue phased expansion of interventions.
Treatment and Care
-Strengthening treatment and care by ensuring quality of care, reducing barriers to access and increasing uptake of services.
World Bank Response
The World Bank was the largest financer of HIV/AIDS programs in Pakistan. It assisted the government’s HIV/AIDS efforts through funding the second Social Action Program (1998‐2003). In addition, the World Bank worked with the government and other development partners (CIDA, DFID, USAID, and UN agencies) to support the government’s program through the HIV/AIDS Prevention Project. The Bank provided US$37.1 million, 75 percent of which was a no‐interest credit and 25 percent of which was grant money. The project which closed in December 2009 supported HIV prevention services to most at risk groups, mass media campaigns aimed at raising awareness and reducing stigma, promoting safe blood transfusion and building management and institutional capacity.
The implementation of targeted intervention made encouraging progress with expanding coverage of an injecting drug users program in Punjab; implementation of service delivery packages for male and female sex workers in Sindh, Punjab and NWFP; jail inmates in Sindh and truckers nationwide. The data from four rounds of surveillance indicate that HIV prevention services did make a difference as reflected in a reduction in risk behaviors most notably among injecting drug users. At the same time the coverage of these interventions was limited covering barely 15‐20 percent of the most at risk groups of injecting drug users and sex workers. The most important issue relates to mobilizing resources and capacity for scaling up services to the high risk populations. Significant challenges also relate to building capacity of the federal and provincial programs and of the implementing NGOs and of developing an effective system to monitor quality and coverage of services.
The Bank is committed to supporting the Government’s Program over the next phase through a more integrated sector wide approach ensuring that the provincial programs are reflected in the government budget and have adequate resources available for implementation, focusing particularly on increasing service coverage of most at risk groups in all major urban centers, improving access and quality of treatment and care and strengthening the monitoring and evaluation system.