Injecting Drug Users and HIV/AIDS in Pakistan Zafar Fatmi Associate Professor & Head Division of Environmental Health Sciences Department of Community Health Sciences Aga Khan University

Acknowledgment The information for this talk has been obtained from National AIDS Control Program website http://www.nacp.gov.pk/ and published reports

Golden Crescent & Golden Triangle (UN office on Drugs and Crime – UNODC, Pakistan)

Drug use in Pakistan There has also been a shift towards injection drug use from inhalation or sniffing National surveillance data indicate that injection drug users (IDUs) have been driving the HIV epidemic in Pakistan

Public health professionals from Pakistan recognize the importance of conducing research on IDU since the early 90s. The data for this publication was collected in 1996.

Results of IJID article - 1996 Cross sectional survey among IDUs in Karachi in 1996. Of the 242 IDUs who consented to provide a blood sample “ONE (1)” was confirmed HIV positive. [Prevalence=0.4%] 47% had reported sharing needles. 22% reported indulging in unsafe sex.

IDUs in Pakistan (2011) Population 15-49 yrs No of IDUs IDUs per 1000 Adult males Both sexes Male Punjab total 9,303,044 4,781,942 15,932 3.3 Sind Total 12,286,980 5,917,679 27,040 4.5 KPK Total 2,004,646 1,047,911 2,343 2.2 Balochistan Total 914,103 498,125 1,034 2.0 All cities mapped total 24,508,773 12,245,657 46,349 3.7

Pakistan in a Concentrated Phase of HIV Since 2004 Pakistan has been in a concentrated phase of the HIV epidemic. HIV prevalence among IDUs in Pakistan has been consistently >5% for many years now.

HIV Prevalence in Risk Groups-2011 Ref: HASP National Dissemination January, 2012, Islamabad

Ref: Emmanuel, HASP National Dissemination January, 2012, Islamabad HIV in Risk Groups 2004 to 2011 Ref: Emmanuel, HASP National Dissemination January, 2012, Islamabad

Comparison of HIV in Regional Cities

Pakistan’s Epidemic in Context Asian epidemics often ignited by IDU epidemics and expanded and sustained by sex work networks.

“Concentrated” Epidemics – A Basic Overview “Bridge” Population “General” Population Key Population (e.g. SW, IDU)

Model Development Observed levels and trends in HIV prevalence: the start year of the epidemic the rate of growth of the epidemic the proportion of the population who are at risk at the start of the epidemic the recruitment rate [or the rate at which at risk people who die due to AIDS or otherwise leave are replaced by new at risk individuals]

Estimated HIV Prevalence in Karachi

Estimated HIV Prevalence in Lahore

What should be Pakistan’s Strategic Priority? Effective harm reduction programs for IDUs Rehabilitation and drug substitution therapy immediately needed

Harm Reduction Program Harm reduction services provided in Pakistan since 2000. Services are interrupted due to administrative and bureaucratic hurdles Some key services are: Syringe and needle exchange program (SNEP) Syndromic management of sexually transmitted infection (STIs) Referral services to HIV positive IDUs to the ARV Center of Sindh AIDS Control Program Primary health care services Social services such as bathing, hair cut, nail clipping, occasionally providing clothes etc. Wound dressing and abscess drainage

Harm Reduction Programs in Karachi Three NGOs: Pakistan Society Al Nijat Welfare Bridge Consultants Foundation If their services reach optimum coverage level we can definitely see a reduction in HIV prevalence among IDUs