An update on HIV/AIDS and An update on HIV/AIDS and STDs in Pakistan: STDs in Pakistan:

epidemiological trends over the epidemiological trends over the last decadelast decade

Sharaf Ali Shah MBBS, Sharaf Ali Shah MBBS,

Ashraf Memon MBBSAshraf Memon MBBS, Omar Khan MD, , Omar Khan MD,

Sten Vermund MD, Sibylle Kristensen Sten Vermund MD, Sibylle Kristensen PhDPhD

Objectives:Objectives:

HIV/AIDS situation in Pakistan. HIV/AIDS situation in Pakistan. This study describes HIV/AIDS This study describes HIV/AIDS

situation in Pakistan with situation in Pakistan with particularly focus on Sindh particularly focus on Sindh Province.Province.

Risk and trendsRisk and trends National / Provincial response.National / Provincial response.

BackgroundBackground

Pakistan statistics in generalPakistan statistics in general

Total population (mid year, 2001):Total population (mid year, 2001): 140.5 million 140.5 million (Economic Survey, (Economic Survey,

Finance Division 2000-2001) Finance Division 2000-2001)

Urban Population: Urban Population: 32.5% 32.5% (Economic Survey, 2000-2001)(Economic Survey, 2000-2001)

Annual population growth rate: Annual population growth rate: 2.1% 2.1% (Economic Survey, 2000- 2001) (Economic Survey, 2000- 2001)

Maternal mortality rate Maternal mortality rate (per 100,000 live births:(per 100,000 live births: 533 533

(National Institute of (National Institute of Population Studies GOP, 2001) Population Studies GOP, 2001)

Infant mortality rateInfant mortality rate 89.889.8 (Economic Survey, 2000-2001) (Economic Survey, 2000-2001)(per 1,000 live birth): (per 1,000 live birth):

Life Expectancy at birth:Life Expectancy at birth: 62.5 years62.5 years (Economic Survey, 2000-2001)(Economic Survey, 2000-2001)

Literacy rate:Literacy rate: Male 56.5% Male 56.5% Female 32.6%Female 32.6% (Economic Survey, 2000-2001)(Economic Survey, 2000-2001)

Per capita GNP (US$)Per capita GNP (US$) 429429 (Economic Survey, 2000-2001) (Economic Survey, 2000-2001)

UNDP Human DevelopmentUNDP Human Development 135 135 (of 174) countries ranking: (of 174) countries ranking: UNDP Human Development UNDP Human Development

Report 2000 Report 2000

Surface Area:Surface Area: KmKm2 2 796,095 796,095 (Pakistan Statistical Yearbook 2001)(Pakistan Statistical Yearbook 2001)

BackgroundBackground

HIV/AIDS Situation in HIV/AIDS Situation in PakistanPakistan

First AIDS Case First AIDS Case 19861986 Federal Committee on AIDS Federal Committee on AIDS 19871987 National AIDS Control Program National AIDS Control Program 19881988 Decentralization of National AIDS Decentralization of National AIDS

Control Program Control Program 1994-19951994-1995 National HIV/AIDS strategic plan National HIV/AIDS strategic plan 20002000

HIV/AIDS Situation in HIV/AIDS Situation in PakistanPakistan

Continued……Continued……

Safe Blood Transfusion Legislation Safe Blood Transfusion Legislation Passed by Sindh Assembly Passed by Sindh Assembly 19971997

Safe Blood Transfusion Ordinance Safe Blood Transfusion Ordinance by Federal Government of by Federal Government of Pakistan Pakistan

20022002

Pakistan: Pakistan: Area Wise Distribution of Area Wise Distribution of

HIV/AIDSHIV/AIDS

Sr Sr ##

Areas Areas HIV HIV PositivePositive

AIDS AIDS Cases Cases

Total Total

0101 Federal Federal CentersCenters

306306 3333 339339

0202 PunjabPunjab 377377 4040 417417

0303 SindhSindh 457457 8181 538538

0404 NWFPNWFP 327327 5252 379379

0505 BalochistaBalochistann

180180 1212 192192

0606 AJKAJK 1717 0404 2121

Total Total 16641664 222222 18861886

Pakistan: Year wise distribution of HIV/AIDS CasesPakistan: Year wise distribution of HIV/AIDS CasesYear Year HIV Positive HIV Positive AIDS Cases AIDS Cases Total Total

19861986 2323 0606 2929

19871987 2727 0202 2929

19881988 4242 0808 5050

19891989 4949 0909 5858

19901990 6060 0505 6565

19911991 140140 1616 156156

19921992 170170 1818 188188

19931993 173173 1616 189189

19941994 178178 0909 187187

19951995 242242 1919 261261

19961996 7676 2020 9696

19971997 112112 1919 131131

19981998 7070 2323 9393

19991999 7272 1717 8989

20002000 115115 1515 130130

20012001 115115 2020 135135

Total Total 16641664 222222 18861886

Pakistan: Age wise distribution of AIDS CasesPakistan: Age wise distribution of AIDS Cases

Age Age Male Male FemaleFemale Total Total %%00-0400-04 0202 0303 0505 2.252.25

05-0905-09 0202 ---- 0202 0.90.9

10-1410-14 ---- ---- ---- ----

15-1915-19 0101 ---- 0101 0.450.45

20-2420-24 0505 0101 0606 2.7022.702

25-2925-29 5656 0404 6060 27.0227.02

30-3430-34 2828 1010 3838 17.1217.12

35-3935-39 2323 0606 2929 13.0613.06

40-4440-44 3030 ---- 3030 13.5113.51

45-4945-49 2323 ---- 2323 10.3610.36

50-5450-54 1313 ---- 1313 5.865.86

55-5955-59 0606 0101 0707 3.153.15

60+60+ ---- ---- ---- ----

UnknownUnknown 0707 0101 0808 3.63.6

Total Total 196196 2626 222222 100%100%

Pakistan: AIDS Cases by Mode of Pakistan: AIDS Cases by Mode of TransmissionTransmission

Mode of Transmission Mode of Transmission AIDSAIDS Percentage Percentage

Heterosexual Heterosexual 141141 63.5163.51Men having sex with Men having sex with

MenMen1313 5.865.86

Blood/Blood productsBlood/Blood products 1616 7.217.21Injecting drug use Injecting drug use 0202 0.900.90

Mother to childMother to child 0707 3.153.15Other known (specify)Other known (specify) ---- ----

Multiple Multiple ---- ----

UnknownUnknown 4343 19.3719.37

Total Total 222222 100%100%

Pakistan: Sex wise distribution Pakistan: Sex wise distribution of AIDS Casesof AIDS Cases

SexSex AIDS AIDS PercentagePercentage

Male Male 196196 88.388.3

FemaleFemale 2626 11.711.7

Total Total 222222 100%100%

Pakistan: Age wise distribution Pakistan: Age wise distribution ofof

HIV positive cases HIV positive cases

Age Age HIV HIV PercentagePercentage

< 04< 04 2424 1.441.44

05-1405-14 0707 0.420.42

15-1915-19 1313 0.780.78

20-2920-29 359359 21.5721.57

30-3930-39 504504 30.2930.29

40-4940-49 294294 17.6717.67

50>50> 4343 2.582.58

UnknownUnknown 420420 25.2425.24

Total Total 16641664 100%100%

Pakistan:Mode of Transmission Pakistan:Mode of Transmission of of

HIV Positive CasesHIV Positive Cases

Mode of Mode of Transmission Transmission

HIVHIV Percentage Percentage

Heterosexual Heterosexual 675675 40.5640.56

Men having sex Men having sex with Menwith Men

3636 2.162.16

BisexualBisexual 2424 1.441.44

Blood/Blood Blood/Blood products products

280280 16.8316.83

Injecting drug Injecting drug usersusers

5555 3.313.31

Mother to ChildMother to Child 2424 1.441.44

UnknownUnknown 570570 34.2534.25

Total Total 16641664 100%100%

Pakistan: Sex wise distribution Pakistan: Sex wise distribution of of

HIV Positive casesHIV Positive cases

SexSex HIVHIV PercentagePercentage

Male Male 14471447 8787

FemaleFemale 217217 1313

Total Total 16641664 100%100%

WHO/UNAIDS FORECAST WHO/UNAIDS FORECAST MODEL ESTIMATES THE MODEL ESTIMATES THE NUMBER TO BE NUMBER TO BE APPROXIMATELY, APPROXIMATELY, 70,000 – 70,000 – 80,00080,000

The HIV/AIDS situation in The HIV/AIDS situation in SindhSindh

Total Population:Total Population: 40 million 40 million Total cases reported to date: Total cases reported to date: 550550 Asymptomatic HIV-positive: Asymptomatic HIV-positive:

455 455 Full-Blown AIDS (WHO criteria) Full-Blown AIDS (WHO criteria) 9595

– Gender breakdown: Gender breakdown: 88.9% male88.9% male 11.1% female11.1% female

-Cases reported as of 31-Cases reported as of 31stst March 2002 March 2002

The HIV/AIDS situation in The HIV/AIDS situation in SindhSindh

Mode of transmission:Mode of transmission:

Heterosexual Heterosexual 87% 87% Male-to-male sex Male-to-male sex 2% 2% Infected blood & blood productsInfected blood & blood products

7% 7% Maternal transmission Maternal transmission 4%4%

The HIV/AIDS situation in The HIV/AIDS situation in SindhSindh

Number of cases reported in 2000Number of cases reported in 2000 3636

MalesMales 29 (80%)29 (80%)

FemalesFemales 07 (20%) 07 (20%)

Number of cases reported in 2001Number of cases reported in 2001 3737

MalesMales 31 (84%)31 (84%)

FemalesFemales 06 (16%) 06 (16%)

Results of HIV, Syphilis, Hepatitis C Results of HIV, Syphilis, Hepatitis C Seroprevalence surveys conducted in Seroprevalence surveys conducted in

yearyear 2001-2002 2001-2002

HIVHIV SyphilisSyphilis Hepatitis CHepatitis C Sample SizeSample SizeI/v Drug usersI/v Drug users 0%0% 15% 15% 85% 85% 319 319

Female Sex WorkersFemale Sex Workers 0.28%0.28% 21% 21% - - 346346

Hijras (Transsexual/Hijras (Transsexual/ 00 31% 31% - - 414414 Transvestites)Transvestites)Truckers Truckers 00 12% 12% - - 300300

Prisoners Prisoners 0.18%0.18% 11% 11% - - 535 535

Antenatal AttendeesAntenatal Attendees 00 0.5% 0.5% - - 20002000

Risks and TrendsRisks and Trends

Younger Population: 63% of Pakistani Younger Population: 63% of Pakistani Population is below 25 years.Population is below 25 years.

Unsafe Sexual PracticesUnsafe Sexual Practices Low use of condoms and barrier Low use of condoms and barrier

methodsmethods Low awareness regarding HIV Low awareness regarding HIV

transmission and low perception of transmission and low perception of riskrisk

Risk and TrendsRisk and Trends The prevalence of Hepatitis B and C in Pakistan is The prevalence of Hepatitis B and C in Pakistan is

one of the highest in the region one of the highest in the region (Hepatitis C(Hepatitis C -- 2-6%)2-6%)(Hepatitis B(Hepatitis B -- 4-10%)4-10%)

Among General PopulationAmong General Population Unsafe Blood Transfusion Practices.Unsafe Blood Transfusion Practices. Source :Source :

Commercial Commercial -- 10-15%10-15% Family Donor-Family Donor- 80%80% VoluntaryVoluntary -- 5-10%5-10%

Lack of Screening Both in Public and Private SectorLack of Screening Both in Public and Private Sector

Unsafe Therapeutic Injection Unsafe Therapeutic Injection PracticesPractices

Irrational Use of InjectionsIrrational Use of Injections Re-usage of Syringes Re-usage of Syringes Recycling of Used Injection Recycling of Used Injection

EquipmentEquipment

Risk and TrendsRisk and Trends

National / Provincial ResponseNational / Provincial ResponseEnhanced HIV/AIDS Control Enhanced HIV/AIDS Control

Program Program Support By World BankSupport By World Bank

Multicultural approach involving Multicultural approach involving Governmental agencies, NGOs, Private Governmental agencies, NGOs, Private sector, Academic Institutions and sector, Academic Institutions and CommunityCommunity

Focusing on vulnerable sub-populations Focusing on vulnerable sub-populations such as Female Sex Workers, Hijras, I/V such as Female Sex Workers, Hijras, I/V Drug Users, Truckers, and Pakistanis Drug Users, Truckers, and Pakistanis working overseas (Gulf Countries)working overseas (Gulf Countries)

National / Provincial National / Provincial ResponseResponse

Continued……..Continued……..

Delivery of comprehensive service package Delivery of comprehensive service package to vulnerable population including peer to vulnerable population including peer education programs, voluntary HIV education programs, voluntary HIV counseling and testing and treatment of counseling and testing and treatment of sexually transmitted infections.sexually transmitted infections.

Behavior change community involving, Behavior change community involving, print and electronic mediaprint and electronic media

Promotion of political commitment through Promotion of political commitment through advocacy. advocacy.

References: our group’s References: our group’s papers on HIV/AIDS in papers on HIV/AIDS in

PakistanPakistan Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon

A. Seroprevalence of HIV, HBV, and syphilis A. Seroprevalence of HIV, HBV, and syphilis and associated risk behaviours in male and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan. transvestites (Hijras) in Karachi, Pakistan. Int Int J STD AIDS J STD AIDS 1999 May;10(5):300-4.1999 May;10(5):300-4.

Ali S, Khanani R, Tarique W U, Shah S A. Ali S, Khanani R, Tarique W U, Shah S A. Understanding the HIV/AIDS context in Understanding the HIV/AIDS context in Pakistan. Pakistan. VenereologyVenereology1995; 8(3):160-3.1995; 8(3):160-3.

Shah SA, Kristensen S, Khan O. HIV/AIDS in Shah SA, Kristensen S, Khan O. HIV/AIDS in Pakistan. Tropical Doctor. 31(1): 59, Jan 2001Pakistan. Tropical Doctor. 31(1): 59, Jan 2001

Khan OA, Hyder AA. Responses to an Khan OA, Hyder AA. Responses to an emerging threat: HIV/AIDS policy in Pakistan. emerging threat: HIV/AIDS policy in Pakistan. Health Policy & PlanningHealth Policy & Planning 2001; 16 (2): 214-8. 2001; 16 (2): 214-8.