The epidemic could be found to have reached adults as well. Experts suspect that it is a marker of systematic failures in health-care provision. Andrew Green reports.
More than 730 people, including almost 600 children, have been diagnosed with HIV in Ratodero, southeast Pakistan, since an outbreak of the virus was reported in late April, according to the Pakistani Government. Experts warn the number might continue to grow as most of the more than 25 000 people who have been screened are women and children, leaving a large portion of the adult population who have not been tested.
“It is safe to say it is an epidemic in children. I have never seen such a large amount of children in the general population involved”, said Fatima Mir, an assistant professor of paediatrics and paediatric infectious diseases at Aga Khan University in Karachi, who was among the early experts brought in to investigate the outbreak. “We haven’t screened enough adults to say if it is actually an epidemic in the adult population, yet.”
Before this outbreak, there were only 1200 children diagnosed with HIV and receiving antiretroviral treatment in all of Pakistan, according to WHO.
Officials in the Sindh province, where Ratodero is located, have set up a paediatric treatment centre and are trying to shore up supplies of antiretroviral drugs as they continue to screen patients and map the disease outbreak. An international team coordinated by WHO is working with local officials to assemble a long-term strategy, Maryam Yunus, a WHO spokesperson, told The Lancet. They expect to present the strategy to provincial and federal officials by mid-June.
Epidemiologists are still attempting to identify the cause of the outbreak. Naseem Salahuddin, the head of the Infectious Disease Department at Indus Hospital in Sindh’s capital, Karachi, told The Lancet that she suspects there is no single source but that the outbreak is the result of years of widespread practice of poor infection control.
She said that, in many communities, patients often turn to small, under-regulated clinics which can provide quick and affordable medical care. Health workers there might reuse needles when giving injections and administering intravenous therapy. There are also unregulated blood banks, which could easily spread the virus.
“To call [infection control] abysmal doesn’t even do justice to how bad it is”, Mir said. The team of local experts who responded to the outbreak in the first few days reported that only a few parents of infected children also had the virus, and that almost all of the children had received multiple injections in the preceding months. “Our working hypothesis is just that there were so many people who kept coming in and out of these clinics”, Mir said, “there was a constant contamination of needles that were reused and reused and reused.”
The outbreak came to national and international attention at the end of April after a local paediatrician flagged at least eight patients who appeared with unusual illnesses He suspected HIV and had them tested. When the results came back positive, broader screening began. And as the number of infected patients swelled, provincial officials set up a paediatric HIV treatment centre at a hospital in the nearby city of Larkana and began linking patients to care. They also called in local experts to begin phylogenetic analysis. The international team of experts organised by WHO arrived soon after.
Even as the investigation continues, officials are working to improve infection control practices. Local media reports that officials have shut down unlicensed clinics and blood banks. And the district is grappling with rapidly building up the programme to provide long-term care to infected patients.
Salahuddin said the government would have to work with international agencies to increase its supply of antiretroviral drugs, particularly paediatric formulations. Officials have said they have enough supplies to provide treatment for a few months, but they are working through global procurement processes to rapidly access additional drugs.
But Mir said they will also need to link HIV services to a broader spectrum of health services for children, including treatment for malnutrition, tuberculosis, and opportunistic infections. “There are so many health problems other than just HIV”, she said.
Officials will also have to set up support systems to remind people to access their medicines and to seek treatment when they have other infections. Yunus said there are probably also going to be efforts to improve knowledge about HIV prevention and treatment through community outreach. “We will have to bring about behavioural and social change in the community”, she said, where knowledge about HIV prevention and treatment is low.
“It is a mammoth task”, Salahuddin said. “It is mind boggling to think how [government officials] are going to deal with this.”