Several nosocomial HIV outbreaks have been investigated in Pakistan. We are aware of three reported here. If you are aware of other outbreaks, please advise!
Sargodha communities, 2017-18
Beginning not later than July 2017, reports from communities near Sargodha report clusters of HIV infections attributed to unsafe healthcare.
Chiniot, 31 July 2017: After initial reports of HIV in a village near Chiniot, health officials set up a camp to test residents. Seventy came for tests, of which 42 tested HIV-positive: 27 women, 17 men, and a 7 year old girl. The article reporting these infections quotes a doctor: “It’s a misconception that HIV is contracted because of sexual contact only. It also spreads if an infected blood syringe or shaving blade is used. The use of infected blood in a transfusion also causes it.”
Kot Imrana, 16 March 2018: A newspaper reports 100 people recently tested HIV-positive in the Kot Imrana region. The local District Health Authority Chief Executive Officer Dr Nusrat Riaz “told the publication that the disease had mainly spread in the area due to the use of one syringe on multiple [people] by a local quack.”
Kot Imrana, 19 March 2018: After reports of HIV in the Kot Imrana locality, health officials collected blood from 2,757 people and sent it for tests. On 19 March, a newspaper reported results from 1,406 samples — of which 204 were HIV-positive. As of early April, results from the other 1,000-plus samples have not been reported.
After reports of HIV infection among persons getting dialysis at the Chandka Medical College, Pakistan’s National AIDS Control Program investigated. The investigation found that 56 (27.3%) of 205 dialysis patients were HIV-positive. “The report mentions that infection control practices were few..”
Jalalpur Jattan, 2008
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 some unexpected HIV infections. 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 many people the 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 team’s report that 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?
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.
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 identified 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 infecting people. Over the last several years, at least 700 residents have been identified with HIV.
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 same monster threatens other countries.
1. Islam S. AIDS scare in a Chiniot village as 42 residents test positive for HIV. The Express Tribute, 31 July 20178. Available at: https://tribune.com.pk/story/1470850/aids-scare-chiniot-village-42-residents-test-positive-hiv/ (accessed 4 April 2018).
2. 100 more p;eople tested positive for HIV/AIDS: report. Monitoring report, 16 March 2018. Available at: https://www.pakistantoday.com.pk/2018/03/16/100-more-people-tested-positive-for-hivaids-report/ (accessed 4 April 2018).
3. 204 patients test positive for HIV/AIDS in Sarghoda. Dunya News, 19 March 2018. Available at: https://dunyanews.tv/en/Pakistan/431865-patients-test-positive-HIV/AIDS-Sargodha (accessed 4 April 2018).
4. Altaf A, Pasha S, Vermund SH, Shah SA. A second major HIV outbreak in Larkana, Pakistan. J Pak Med Assoc 2016; 66: 1510-1511. Available at: http://jpma.org.pk/full_article_text.php?article_id=7991 (accessed 4 April 2018).