2. An update on HIV/AIDS and STDs in Pakistan: epidemiological trends over the last decade Sharaf Ali Shah MBBS, Ashraf Memon MBBS, Omar Khan MD, Sten Vermund MD, Sibylle Kristensen PhD

3. Objectives: n HIV/AIDS situation in Pakistan. n This study describes HIV/AIDS situation in Pakistan with particularly focus on Sindh Province. n Risk and trends n National / Provincial response.

4. Background n Pakistan statistics in general n Total population (mid year, 2001):140.5 million (Economic Survey, Finance Division 2000-2001) n Urban Population: 32.5% (Economic Survey, 2000-2001) (Economic Survey, 2000-2001) n Annual population growth rate: 2.1% (Economic Survey, 2000- 2001) n Maternal mortality rate (per 100,000 live births: 533 (National Institute of Population Studies GOP, 2001) (National Institute of Population Studies GOP, 2001)

5. n Infant mortality rate 89.8 (Economic Survey, 2000-2001) (per 1,000 live birth): n Life Expectancy at birth: 62.5 years (Economic Survey, 2000-2001) (Economic Survey, 2000-2001) n Literacy rate: Male 56.5% Female 32.6% (Economic Survey, 2000-2001) (Economic Survey, 2000-2001) n Per capita GNP (US$) 429 (Economic Survey, 2000-2001) n UNDP Human Development 135 (of 174) countries ranking: UNDP Human Development Report 2000 n Surface Area: Km 2 796,095 (Pakistan Statistical Yearbook 2001) (Pakistan Statistical Yearbook 2001) Background

6. HIV/AIDS Situation in Pakistan n First AIDS Case 1986 n Federal Committee on AIDS 1987 n National AIDS Control Program 1988 n Decentralization of National AIDS Control Program 1994-1995 Control Program 1994-1995 n National HIV/AIDS strategic plan 2000

7. HIV/AIDS Situation in Pakistan Continued…… n Safe Blood Transfusion Legislation Passed by Sindh Assembly 1997 n Safe Blood Transfusion Ordinance by Federal Government of Pakistan 2002 2002

8. Pakistan: Area Wise Distribution of HIV/AIDS Sr # Areas HIV Positive AIDS Cases Total 01 Federal Centers 30633339 02Punjab37740417 03Sindh45781538 04NWFP32752379 05Balochistan18012192 06AJK170421 Total16642221886

9. Pakistan: Year wise distribution of HIV/AIDS Cases Year HIV Positive AIDS Cases Total 1986230629 1987270229 1988420850 1989490958 1990600565 199114016156 199217018188 199317316189 199417809187 199524219261 1996762096 199711219131 1998702393 1999721789 200011515130 200111520135 Total16642221886

10. Pakistan: Age wise distribution of AIDS Cases AgeMaleFemaleTotal% 00-040203052.25 05-0902--020.9 10-14-------- 15-1901--010.45 20-240501062.702 25-2956046027.02 30-3428103817.12 35-3923062913.06 40-4430--3013.51 45-4923--2310.36 50-5413--135.86 55-590601073.15 60+-------- Unknown0701083.6 Total19626222100%

11. Pakistan: AIDS Cases by Mode of Transmission Mode of Transmission AIDSPercentage Heterosexual14163.51 Men having sex with Men 135.86 Blood/Blood products 167.21 Injecting drug use 020.90 Mother to child 073.15 Other known (specify) ---- Multiple---- Unknown4319.37 Total222100%

12. Pakistan: Sex wise distribution of AIDS Cases SexAIDSPercentage Male19688.3 Female2611.7 Total222100%

13. Pakistan: Age wise distribution of HIV positive cases AgeHIVPercentage < 04 241.44 05-14070.42 15-19130.78 20-2935921.57 30-3950430.29 40-4929417.67 50>432.58 Unknown42025.24 Total1664100%

14. Pakistan:Mode of Transmission of HIV Positive Cases Mode of Transmission HIVPercentage Heterosexual67540.56 Men having sex with Men 362.16 Bisexual241.44 Blood/Blood products 28016.83 Injecting drug users 553.31 Mother to Child 241.44 Unknown57034.25 Total1664100%

15. Pakistan: Sex wise distribution of HIV Positive cases SexHIVPercentage Male144787 Female21713 Total1664100%

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

17. The HIV/AIDS situation in Sindh n Total Population: 40 million n Total cases reported to date: 550 n Asymptomatic HIV-positive: 455 n Full-Blown AIDS (WHO criteria) 95 – Gender breakdown: 88.9% male 88.9% male 11.1% female 11.1% female -Cases reported as of 31 st March 2002

18. The HIV/AIDS situation in Sindh n Mode of transmission: n Heterosexual 87% n Male-to-male sex 2% n Infected blood & blood products7% n Maternal transmission 4%

19. The HIV/AIDS situation in Sindh n Number of cases reported in 200036 Males29 (80%) Females 07 (20%) n Number of cases reported in 200137 Males31 (84%) Females 06 (16%)

20. Results of HIV, Syphilis, Hepatitis C Seroprevalence surveys conducted in year 2001-2002 HIVSyphilis Hepatitis C Sample Size I/v Drug users0% 15% 85% 319 Female Sex Workers0.28% 21% -346 Hijras (Transsexual/0 31% -414 Transvestites) Transvestites) Truckers 0 12% -300 Prisoners 0.18% 11% - 535 Antenatal Attendees0 0.5% - 2000

21. Risks and Trends n Younger Population: 63% of Pakistani Population is below 25 years. n Unsafe Sexual Practices n Low use of condoms and barrier methods n Low awareness regarding HIV transmission and low perception of risk

22. Risk and Trends n The prevalence of Hepatitis B and C in Pakistan is one of the highest in the region (Hepatitis C-2-6%) (Hepatitis B-4-10%) Among General Population n Unsafe Blood Transfusion Practices. n Source : n Commercial -10-15% n Family Donor-80% n Voluntary-5-10% n Lack of Screening Both in Public and Private Sector

23. n Unsafe Therapeutic Injection Practices n Irrational Use of Injections n Re-usage of Syringes n Recycling of Used Injection Equipment Risk and Trends

24. National / Provincial Response Enhanced HIV/AIDS Control Program Support By World Bank n Multicultural approach involving Governmental agencies, NGOs, Private sector, Academic Institutions and Community Focusing on vulnerable sub-populations such as Female Sex Workers, Hijras, I/V Drug Users, Truckers, and Pakistanis working overseas (Gulf Countries) Focusing on vulnerable sub-populations such as Female Sex Workers, Hijras, I/V Drug Users, Truckers, and Pakistanis working overseas (Gulf Countries)

25. National / Provincial Response Continued…….. n Delivery of comprehensive service package to vulnerable population including peer education programs, voluntary HIV counseling and testing and treatment of sexually transmitted infections. n Behavior change community involving, print and electronic media n Promotion of political commitment through advocacy.

26. References: our group’s papers on HIV/AIDS in Pakistan n Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon A. Seroprevalence of HIV, HBV, and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan. Int J STD AIDS 1999 May;10(5):300-4. n Ali S, Khanani R, Tarique W U, Shah S A. Understanding the HIV/AIDS context in Pakistan. Venereology1995; 8(3):160-3. n Shah SA, Kristensen S, Khan O. HIV/AIDS in Pakistan. Tropical Doctor. 31(1): 59, Jan 2001 n Khan OA, Hyder AA. Responses to an emerging threat: HIV/AIDS policy in Pakistan. Health Policy & Planning 2001; 16 (2): 214-8.