Pakistan’s growing HIV epidemic

Diagnoses are growing and experts fear that infection is moving from key populations to the public at large. Udani Samarasekera reports.

UN health agencies and local experts are concerned about the spread of HIV in Pakistan. New HIV infections continue to grow, with an 84% increase between 2010 and 2022. Around 25 000 new HIV infections were estimated to have occurred in 2021, and 27 000 are projected for 2022. The country remains one of the few countries in Asia Pacific Region in which new HIV infections are rising. UNAIDS called the country’s HIV situation “a major cause of concern”.

National data suggest 8262 people have been newly diagnosed with HIV from January to September in 2022, including 496 from Islamabad Capital Territory. Experts speaking to The Lancet noted that the high number is unusual but is likely to be due to increased testing. UNAIDS Country Director for Pakistan, Yuki Takemoto said: “Reports about sharp increases in new HIV infections in various parts of the country are very alarming and UNAIDS, together with other partners, is supporting efforts by the government to assess the situation”.

Modelling by WHO and UNAIDS suggests that new HIV infections are increasing in all four of Pakistan’s provinces. But most patients live in just two provinces. Of the 210 000 people living with HIV in Pakistan, 50% are in Punjab and 43% in Sindh. The epidemic remains largely concentrated in key populations, including people who inject drugs, the transgender community, sex workers, and men who have sex with men (MSM). HIV transmission via needle sharing among people who inject drug remains the most common means of transmission. However, sexual transmission in MSM who are not sex workers is expected to account for the bulk of new infections if intervention efforts are not ramped up.

Experts are now worried about the epidemic moving into the general population. 2019 saw more new infections in people considered to be at low risk of HIV infection, suggesting an increase in transmission to bridging populations (spouses, partners, and clients) of key populations. Muhammad Pasha, WHO’s HIV expert in Pakistan, said that increasing new infections in the country are coupled with increased case detection due to enhanced HIV testing services, adding that “expanding targeted testing programmes to cover spouses and family members of key populations” is needed.

A 2019 outbreak of HIV in Sindh showed how the epidemic can move into the general population. From April to December, 2019, more than 800 children and 200 adults tested positive for HIV in the outbreak, which was driven by unsafe injection practices and poor blood safety practices in health-care settings. Fatima Mir, Associate Professor in the Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan, said that some measures, such as a blood transfusion safety programme with registration for blood banks, were put in place after the outbreak. But the “demand overshadows the supply and people are still going to unregistered blood places”, she told The Lancet.

Mir fears that key populations are now bridging with the general population. “Populations who were not vulnerable before are now vulnerable. I do feel children are vulnerable. They are vulnerable because of repeated injections. They are vulnerable because of blood transfusions. And they are vulnerable because their mothers are not getting screened in pregnancy”, said Mir. Abbas Abid, Senior Instructor, Department of Pathology and Laboratory Medicine, Aga Khan University, added “we’re not really sure if we can say that it has spread to the general population, but this is the trend it’s going towards and that’s scary”.

The country is off-track for the UNAIDS 90-90-90 targets, aiming to diagnose 90% of all HIV positive people, provide antiretroviral therapy (ART) for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020. Only 21% of people living with HIV in Pakistan are aware of their status and just 12% are on treatment. “I don’t know how long it’s going to take [to get to 90-90-90] but it’ll take a lot of work”, said Abid. “We should assign goals for 2025 and 2030. If you cannot achieve the 90-90-90 status, you can try getting to around 70-70-70 or something similar”, he added.

Pasha thinks that new initiatives should be piloted, including pre-exposure prophylaxis for HIV prevention (PrEP), HIV self-testing, and opiate agonist therapy. Takemoto said: “Equally critical are the meaningful engagement and leadership of the most affected communities to address gaps in awareness, access to prevention tools, and other root causes of vulnerability.” Mir notes that education about PrEP and HIV testing services is crucial. “High-risk groups should know they can access PrEP from HIV treatment centres and that testing is available free of cost. I think this is information which needs to be out there and repeated”, she said.