Unexpected HIV infections in children and adults, 2008 and later: In 2008, a voluntary counseling and HIV testing (VCT) center near Jalalpur Jattan town in Gujrat, Pakistan, noted an unexpectedly large number of people with HIV infections. Across Pakistan, an estimated 1 in 1,000 adults are infected. The situation in Jalalpur Jattan town seemed much worse.
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 Jalalpur Jattan in June-July 2008. During these two days, 246 people came for testing, and 88 were found to be HIV-positive.
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 collected from the 88 who tested HIV-positive in the two 1-day testing camps plus 3 others tested elsewhere. The resulting report concluded that many infections came from “local medics (quacks) who have not been observing the sterilization and infection control techniques…” The report considered that therapeutic injections were the primary risk for 28 of 52 HIV-positive females (of all ages, including children) and for 4 of 36 males. This was a desk study. Because it did not trace and test others who visited various medical facilities, it could not determine which quacks and/or trained providers infected patients, how many people had been infected, and the time-line for the outbreak.
The high number of people that New Light AIDS Control Society found to be HIV-positive in only two days of testing got the attention of Pakistan’s National AIDS Control Program in the Ministry of Health. In November 2008, a team from the Ministry of Health made a 1-day visit to Jalalpur Jattan. It’s clear from the short report the team wrote about their visit that influential health officials did not want New Light AIDS Control Society to play any further role in uncovering and explaining what was happening in Jalalpur Jattan — but why? Is it because the outbreak embarrassed health officials by showing that health care was not safe?
The Ministry of Health’s 1-day visit could not answer the big questions? How did so many people get HIV? And how to stop the outbreak? To answer those questions, Pakistan’s National Institute of Health assigned experts from Pakistan’s Field Epidemiology & Laboratory Training Program (FELTP) to investigate the situation, with assistance from the US Centers for Disease Control and Prevention (CDC).
The resulting “Report on HIV/AIDS Outbreak Investigation at Jalalpur Jattan (JPJ), Gujarat” is better termed a cover-up than an investigation (to protect the confidentiality of people with HIV, this link omits family trees on pages 36-48). The terms of reference were clear, instructing the team to: “determine the extent and chain of transmission” and to “identify…sites of potential transmission.” FELPT’s study did neither — a failure that seems to have been by design.
Because it was fairly clear that unsafe healthcare was driving the outbreak, what was required was to trace and test people who had visited suspected facilities. The FELTP team didn’t do that. 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). The resulting report contains a lot of family trees, but no trees linking infections to specific clinics and skin-piercing procedures.
The study team spent less than 3 weeks in Jalalpur Jattan town — 15 December 2008 to 2 January 2009. Overall, the team indentified 53 persons with HIV, including 26 previously tested.
The FELTP team noted that 95% of investigated cases reported therapeutic injections and many reported surgeries and dental care. But instead of digging further to go from suspicion to confirmation and to identify the sources of the infections, the FELTP team stopped at suspicion: “These observations in the presence of the poor sterilization practices could have promoted the spread of HIV and other blood borne viruses.”
Because the US CDC and FELTP dropped the ball, residents of Jalalpur Jattan still do not know how so many got infected, and there is no assurance that the sources for the observed infections have stopped pumping pumping HIV into the community. Over the last several years, at least 700 residents have been identified with HIV through voluntary counseling and testing (VCT) clinics.
Foreign advice for HIV prevention in Pakistan has focused on stigmatized behavior (male-male sex, injection drug use, and commercial sex), supposing these behaviors are the major threat to spread HIV in Pakistan. But is that so? Based on what happened — is it still happening? — in Jalalpur Jattan, “bad” behaviors are not the biggest threat. Only a minority of HIV-positive people in Jalalpur Jattan got HIV through stigmatized behaviors.
The HIV outbreak in Jalalpur Jattan calls attention to the biggest risk to spread HIV in Pakistan — unsafe health care. Pakistan already has one of the worst epidemics of hepatitis C in the world due to unsterile practices during health care and cosmetic services. Hepatitis B is also common in the general population. Both hepatitis B and C were introduced a long time ago, and so have had more time to spread. In this link, Sohail Rabbani vividly characterizes hepatitis B, C, and HIV as a Three Headed Monster threatening Pakistan. The monster threatens other countries, too.