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

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.

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

n Infant mortality rate 89.8 (Economic Survey, ) (per 1,000 live birth): n Life Expectancy at birth: 62.5 years (Economic Survey, ) (Economic Survey, ) n Literacy rate: Male 56.5% Female 32.6% (Economic Survey, ) (Economic Survey, ) n Per capita GNP (US$) 429 (Economic Survey, ) 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

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 Control Program n National HIV/AIDS strategic plan 2000

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

Pakistan: Area Wise Distribution of HIV/AIDS Sr # Areas HIV Positive AIDS Cases Total 01 Federal Centers Punjab Sindh NWFP Balochistan AJK Total

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

Pakistan: Age wise distribution of AIDS Cases AgeMaleFemaleTotal% Unknown Total %

Pakistan: AIDS Cases by Mode of Transmission Mode of Transmission AIDSPercentage Heterosexual Men having sex with Men Blood/Blood products Injecting drug use Mother to child Other known (specify) ---- Multiple---- Unknown Total222100%

Pakistan: Sex wise distribution of AIDS Cases SexAIDSPercentage Male Female Total222100%

Pakistan: Age wise distribution of HIV positive cases AgeHIVPercentage < > Unknown Total %

Pakistan:Mode of Transmission of HIV Positive Cases Mode of Transmission HIVPercentage Heterosexual Men having sex with Men Bisexual Blood/Blood products Injecting drug users Mother to Child Unknown Total %

Pakistan: Sex wise distribution of HIV Positive cases SexHIVPercentage Male Female21713 Total %

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

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

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%

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

Results of HIV, Syphilis, Hepatitis C Seroprevalence surveys conducted in year 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% Antenatal Attendees0 0.5%

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

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 % n Family Donor-80% n Voluntary-5-10% n Lack of Screening Both in Public and Private Sector

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

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)

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.

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): n Ali S, Khanani R, Tarique W U, Shah S A. Understanding the HIV/AIDS context in Pakistan. Venereology1995; 8(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):