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Raza HA, Raja MHR, Khakwani MM, Jamil B. Pakistan's HIV high-risk populations: Critical appraisal of failure to curtail spread beyond key populations. IJID REGIONS 2024; 11:100364. [PMID: 38660580 PMCID: PMC11039346 DOI: 10.1016/j.ijregi.2024.100364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/26/2024]
Abstract
Pakistan has been a hub of several HIV outbreaks over the last 2 decades, with four major outbreaks being registered since 2018. There has been a recent rise in HIV infections, especially in high-risk populations, mainly consisting of people who inject drugs, men who have sex with men, prisoners, the transgender women community, and female sex workers. Consistently poor infection control practices, unregulated unsafe blood transfusion, questionable ethical practices by healthcare providers, and a general lack of awareness are the main drivers of recent HIV outbreaks, with these issues exacerbated by the presence of untrained health care providers. To stop the spread of HIV systemically and sustainably, aggressive measures need to be taken at all levels by all concerned stakeholders that not only deal with building up testing, tracing, and treatment capabilities but also address underlying grassroots problems that have largely been ignored to date.
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Affiliation(s)
- Hussain Ahmed Raza
- Department for Educational Development, The Aga Khan University, Karachi, Pakistan
| | | | | | - Bushra Jamil
- Section of Infectious Diseases, Department of Medicine, The Aga Khan University Hospital, National Coordinator (2021), Common Management Unit for Global Funds (AIDS, TB and Malaria Grants), Ministry of National Health Services Regulations and Coordination, Karachi, Pakistan
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Nisa SU, Mahmood A, Ujager FS, Malik M. HIV/AIDS predictive model using random forest based on socio-demographical, biological and behavioral data. EGYPTIAN INFORMATICS JOURNAL 2022. [DOI: 10.1016/j.eij.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Syed MA, Khan A, Chaudhry A, Baig MA, Memon NM, Kumar S, Bhurt SA, Qadri M, Vighio A, Baig ZI, Rabold EM, Ali H, Blanton C, Asghar RJ, Ikram A, Rahim M, Solangi M, Mahipala P, Fontaine RE. An Epidemic of Pediatric HIV From Reuse of Infusion Equipment in Pakistan. J Acquir Immune Defic Syndr 2022; 89:121-128. [PMID: 34723928 DOI: 10.1097/qai.0000000000002845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND From April to June 2019, a total of 909 new HIV infections were identified in Larkana, Pakistan; 86% was children younger than 15 years. To identify the possible transmission links in this outbreak, a case-control study was conducted in June 2019. METHODS For cases, we selected a systematic random sample of 100 HIV-positive children from the screening list. We chose 2 age-matched and sex-matched controls from the neighborhood of each HIV-positive case. All selected children were tested using the World Health Organization-approved rapid diagnosis test algorithm. We interviewed the parents of each selected child about previous exposures to parenteral treatment and compared exposures of case and control children using conditional logistic regression. RESULTS The ages of the selected children ranged from 1 month to 10 years. More than 90% of both HIV+ and HIV- children had received outpatient health care from MBBS-qualified private physicians. Eighty-three percent of HIV+ children versus 46% of HIV- children had received health care from one private physician [adjusted odds ratio (aOR) = 29, 95% confidence interval (95% CI): 10 to 79]. Intravenous infusions during the last outpatient visit were reported by 29% of case versus 7% of controls (aOR 57, 95% CI: 2.9 to >1000), whereas no case children and 17% of control children had received only intramuscular injections (aOR 0, 95% CI: 0 to 41). Among cases, 94% had been given infusions through a drip set compared with 85% of control children (aOR = 7.7, 95% CI: 2.3 to 26). Infusions had been administered with reused IV drip sets in 70% of cases compared with 8% of controls (aOR = 197, 95% CI: 16 to 2400). DISCUSSION Private physicians reusing intravenous drip sets to treat outpatients seen in private practice were responsible for this HIV epidemic. Mapping and regulation of private practitioners were suggested.
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Affiliation(s)
- Muhammad Asif Syed
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Adnan Khan
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Ambreen Chaudhry
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Mirza Amir Baig
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Naveed Masood Memon
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Santosh Kumar
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Saeed Ahmed Bhurt
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Munaza Qadri
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Anum Vighio
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Zeeshan Iqbal Baig
- Pakistan Field Epidemiology and Laboratory Training Program, Pakistan National Institute of Health Islamabad, Pakistan
| | - Elizabeth M Rabold
- Centers for Disease Control and Prevention, Division of Global HIV/AIDS and Tuberculosis
| | - Hammad Ali
- Centers for Disease Control and Prevention, Division of Global HIV/AIDS and Tuberculosis
| | - Curtis Blanton
- Centers For Disease Control and Prevention, Division of Global Health Protection
| | | | | | - Musa Rahim
- WHO Health Emergencies, WHO Country Office, Islamabad, Pakistan; and
| | | | - Palitha Mahipala
- WHO Health Emergencies, WHO Country Office, Islamabad, Pakistan; and
| | - Robert E Fontaine
- Centers For Disease Control and Prevention, Division of Global Health Protection
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Mir F, Nathwani AA, Simms V, Abidi SH, Siddiqui AR, Hotwani A, Memon SA, Shaikh SA, Soomro J, Shah SA, Achakzai B, Furqan S, Saeed Q, Khan P, Weiss HA, Mahmood SF, Ferrand RA. Factors associated with HIV infection among children in Larkana District, Pakistan: a matched case-control study. Lancet HIV 2021; 8:e342-e352. [PMID: 34087096 DOI: 10.1016/s2352-3018(21)00049-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND In April, 2019, an HIV outbreak predominantly affecting children occurred in Larkana District, Sindh, Pakistan. By December, 2019, 881 (4·0%) of 21 962 children screened for HIV had tested positive. We aimed to assess factors associated with HIV infection in this outbreak. METHODS In this individually matched case-control study, we sampled 406 cases (individuals aged <16 years who had registered for paediatric HIV care at the HIV Treatment Centre at Shaikh Zayed Children's Hospital in Larkana City, Pakistan) and 406 controls (individuals without HIV matched by age, sex, and neighbourhood residence, recruited through doorknocking at houses adjacent to case participants). An interviewer-administered questionnaire was used to collect data on possible risk factors for HIV acquisition and a blood sample was collected from all participants for hepatitis B and hepatitis C serology. Mothers of all participants underwent HIV testing. Odds ratios were estimated using conditional logistic regression to assess factors associated with HIV infection. FINDINGS 406 case-control pairs were recruited between July 3 and Dec 26, 2019. Five pairs were excluded (three pairs had an age mismatch and two pairs were duplicate cases) and 401 were analysed. The prevalence of hepatitis B surface antigen was 18·2% (95% CI 14·5-22·3) among cases and 5·2% (3·3-7·9) among controls, and the prevalence of hepatitis C antibodies was 6·5% (95% CI 4·3-9·4) among cases and 1·0% (0·3-2·5) among controls. 28 (7%) of 397 mothers of cases for whom we had data, and no mothers of 394 controls, were HIV positive. In the 6 months before recruitment, 226 (56%) of 401 cases and 32 (8%) of 401 controls reported having more than ten injections, and 291 (73%) cases and 78 (19%) controls had received an intravenous infusion. At least one blood transfusion was reported in 56 (14%) cases and three (1%) controls in the past 2 years. HIV infection was associated with a history of more injections and infusions (adjusted odds ratio 1·63; 95% CI 1·30-2·04, p<0·0001), blood transfusion (336·75; 23·69-4787·01, p<0·0001), surgery (399·75, 13·99-11 419·39, p=0·0005), the child's mother being HIV positive or having died (3·13, 1·20-8·20, p=0·020), and increased frequency of private clinic (p<0·0001) and government hospital visits (p<0·0001), adjusting for confounders. INTERPRETATION The predominant mode of HIV transmission in this outbreak was parenteral, probably due to unsafe injection practices and poor blood safety practices. General practitioners across Pakistan need training and systems support in reducing injection use, and in providing safe injections and transfusions only when necessary. FUNDING Department of Pediatrics and Child Health, the Aga Khan University, Karachi, Pakistan.
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Affiliation(s)
- Fatima Mir
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Apsara Ali Nathwani
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Victoria Simms
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Syed Hani Abidi
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | | | - Aneeta Hotwani
- Infectious Disease Research Laboratory, Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Saqib Ali Shaikh
- Sindh AIDS Control Programme, Ministry of Health, Sindh, Pakistan
| | - Jamila Soomro
- Public Health Wing, Ministry of Health, Sindh, Pakistan
| | | | | | - Sofia Furqan
- National AIDS Control Program, Islamabad, Pakistan
| | - Quaid Saeed
- National AIDS Control Program, Islamabad, Pakistan
| | - Palwasha Khan
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen A Weiss
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Syed Faisal Mahmood
- Section of Infectious Disease, Department of Internal Medicine, Aga Khan University, Karachi, Pakistan
| | - Rashida Abbas Ferrand
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Rabold EM, Ali H, Fernandez D, Knuth M, Schenkel K, Asghar RJ, Baig MA, Shaikh S, Morgan O. Systematic Review of Reported HIV Outbreaks, Pakistan, 2000-2019. Emerg Infect Dis 2021; 27:1039-1047. [PMID: 33755545 PMCID: PMC8007288 DOI: 10.3201/eid2704.204205] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
In the absence of robust testing programs, timely and detailed outbreak reporting is essential for HIV control. Unsafe injection practices and injection drug use have been linked to multiple HIV outbreaks in Pakistan since 2003; however, few studies have systematically analyzed the causes of these outbreaks. We conducted a systematic review of published English-language literature indexed in bibliographic databases and search engines and a focused gray literature review to collate and analyze all reported HIV outbreaks in Pakistan during 2000–2019. Of 774 unique publications reviewed, we identified 25 eligible publications describing 7 outbreaks. More than half occurred during 2016–2019. The primary sources of transmission were iatrogenic transmission, affecting children, persons with chronic medical conditions, and the general population (4 outbreaks); injection drug use (2 outbreaks); and a combination of both (1 outbreak). In the absence of robust HIV testing and surveillance in Pakistan, timely and detailed outbreak reporting is important to understand the epidemiology of HIV in the country.
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Affiliation(s)
| | | | - Danielle Fernandez
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.M. Rabold, H. Ali, D. Fernandez, M. Knuth)
- World Health Organization, Geneva, Switzerland (K. Schenkel, O. Morgan)
- Global Health Strategists and Implementers, Karachi, Pakistan (R.J. Asghar)
- Pakistan Field Epidemiology and Laboratory Training Program, Karachi (M.A. Baig)
- Sindh AIDS Control Program, Larkana, Pakistan (S. Shaikh)
| | - Martha Knuth
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.M. Rabold, H. Ali, D. Fernandez, M. Knuth)
- World Health Organization, Geneva, Switzerland (K. Schenkel, O. Morgan)
- Global Health Strategists and Implementers, Karachi, Pakistan (R.J. Asghar)
- Pakistan Field Epidemiology and Laboratory Training Program, Karachi (M.A. Baig)
- Sindh AIDS Control Program, Larkana, Pakistan (S. Shaikh)
| | - Karl Schenkel
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.M. Rabold, H. Ali, D. Fernandez, M. Knuth)
- World Health Organization, Geneva, Switzerland (K. Schenkel, O. Morgan)
- Global Health Strategists and Implementers, Karachi, Pakistan (R.J. Asghar)
- Pakistan Field Epidemiology and Laboratory Training Program, Karachi (M.A. Baig)
- Sindh AIDS Control Program, Larkana, Pakistan (S. Shaikh)
| | - Rana Jawad Asghar
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.M. Rabold, H. Ali, D. Fernandez, M. Knuth)
- World Health Organization, Geneva, Switzerland (K. Schenkel, O. Morgan)
- Global Health Strategists and Implementers, Karachi, Pakistan (R.J. Asghar)
- Pakistan Field Epidemiology and Laboratory Training Program, Karachi (M.A. Baig)
- Sindh AIDS Control Program, Larkana, Pakistan (S. Shaikh)
| | - Mirza Amir Baig
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.M. Rabold, H. Ali, D. Fernandez, M. Knuth)
- World Health Organization, Geneva, Switzerland (K. Schenkel, O. Morgan)
- Global Health Strategists and Implementers, Karachi, Pakistan (R.J. Asghar)
- Pakistan Field Epidemiology and Laboratory Training Program, Karachi (M.A. Baig)
- Sindh AIDS Control Program, Larkana, Pakistan (S. Shaikh)
| | - Saqib Shaikh
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.M. Rabold, H. Ali, D. Fernandez, M. Knuth)
- World Health Organization, Geneva, Switzerland (K. Schenkel, O. Morgan)
- Global Health Strategists and Implementers, Karachi, Pakistan (R.J. Asghar)
- Pakistan Field Epidemiology and Laboratory Training Program, Karachi (M.A. Baig)
- Sindh AIDS Control Program, Larkana, Pakistan (S. Shaikh)
| | - Oliver Morgan
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E.M. Rabold, H. Ali, D. Fernandez, M. Knuth)
- World Health Organization, Geneva, Switzerland (K. Schenkel, O. Morgan)
- Global Health Strategists and Implementers, Karachi, Pakistan (R.J. Asghar)
- Pakistan Field Epidemiology and Laboratory Training Program, Karachi (M.A. Baig)
- Sindh AIDS Control Program, Larkana, Pakistan (S. Shaikh)
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Patil S, Rao A, Pathak P, Kurle S, Mane A, Nirmalkar A, Singhal AK, Verma V, Singh MK, Reddy DCS, Shete A, Singh M, Gangakhedkar R, Panda S. Unsterile injection equipment associated with HIV outbreak and an extremely high prevalence of HCV-A case-control investigation from Unnao, India. PLoS One 2020; 15:e0243534. [PMID: 33275646 PMCID: PMC7717531 DOI: 10.1371/journal.pone.0243534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 11/23/2020] [Indexed: 01/30/2023] Open
Abstract
The integrated counseling and testing center (ICTC) located in the district hospital, Unnao in the northern state of Uttar Pradesh (UP), India witnessed an increased detection of HIV among its attendees in July 2017. Subsequently, health camps were organized by the UP State AIDS Control Society in the villages and townships contributing to such detection. We conducted a case-control study to identify factors associated with this increased detection; 33 cases and 125 controls were enrolled. Cases were individuals, detected HIV sero-reactive during November 2017-April 2018 from three locations namely Premganj, Karimuddinpur and Chakmeerapur in the Bangarmau block of the district of Unnao. Controls hailed from the same geographical setting and tested HIV sero-nonreactive either in health camps or at ICTC centers from where the cases were detected. Misclassification bias was avoided by confirming HIV sero-status of both cases as well as controls prior to final analysis. Study participants were interviewed on various risk practices and invasive treatment procedures. They were also tested for HIV and other bio-markers reflecting unsafe injecting and sexual exposures such as hepatitis B surface antigen (HBsAg), anti-HCV antibody (HCV Ab), anti-herpes simplex-2 Immunoglobulin G (HSV-2 IgG) and rapid plasma regain (RPR) test for syphilis. Secondary data analysis on three time points during 2015 through 2018 revealed a rising trend of HIV among attendees of the ICTCs (ICTC-Hasanganj, ICTC-Unnao district hospital and ICTC- Nawabganj) catering to the entire district of Unnao. While there was a seven fold rise of HIV among ICTC attendees of Hasanganj (χ2 value for trend 23.83; p < 0.001), the rise in Unnao district hospital was twofold (χ2 value for trend 4.37; p < 0.05) and was tenfold at ICTC-Nawabganj (χ2 value for trend 5.23; p < 0.05) indicating risk of infection prevailing throughout the district. Primary data was generated through interviews and laboratory investigations as mentioned above. The median age of cases and controls was 50 year (minimum 18 –maximum 68; IQR 31–57) and 38 year (minimum 18 –maximum 78; IQR 29–50) respectively. Thirty six percent of the cases and 47% of controls were male. A significantly higher proportion of cases (85%) had HCV Ab compared to controls (56%; OR 4.4, 95% CI 1.5–12.1); none reported injection drug use. However, cases and controls did not differ significantly regarding presence of HSV-2 IgG (6% versus 8% respectively). Neither any significant difference existed between cases and controls in terms of receiving blood transfusion, undergoing invasive surgical procedures, tattooing, tonsuring of head or skin piercing. In multivariate logistic regression model, ‘unsafe injection exposure during treatment-seeking’(AOR 6.61, 95% CI 1.80–24.18) and ‘receipt of intramuscular injection in last five years’ (AOR 7.20, 95% CI 1.48–34.88) were independently associated with HIV sero-reactive status. The monophyletic clustering of HIV sequences from 14 cases (HIV-1 pol gene amplified) indicated a common ancestry. Availability of auto-disabled syringes and needles, empowerment of the local communities and effective regulatory practices across care settings would serve as important intervention measures in this context.
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Affiliation(s)
- Sandip Patil
- Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India
| | - Amrita Rao
- Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India
| | - Preety Pathak
- Uttar Pradesh State AIDS Control Society, Lucknow, Uttar Pradesh, India
| | - Swarali Kurle
- Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India
| | - Arati Mane
- Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India
| | - Amit Nirmalkar
- Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India
| | - A. K. Singhal
- Community Health Centre, Department of Medical & Health, Government of Uttar Pradesh, Bangarmau, India
| | - Vinita Verma
- National AIDS Control Organization, New Delhi, India
| | - Mukesh Kumar Singh
- Community Health Centre, Department of Medical & Health, Government of Uttar Pradesh, Bangarmau, India
| | - D. C. S. Reddy
- Technical Resource Group, National AIDS Control Organization, New Delhi, India
| | - Ashwini Shete
- Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India
| | - Manjula Singh
- Indian Council of Medical Research Headquarter, New Delhi, India
| | | | - Samiran Panda
- Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India
- Indian Council of Medical Research Headquarter, New Delhi, India
- * E-mail: , ,
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Mansoor E, Azam N, Niazi SK, Sheikh N, Baig MA, Azim MT, Klair N. Rising HIV seroconversion rates & associated risks among employees of organization 'X': A case control study, Pakistan, 2017. Pak J Med Sci 2020; 36:1349-1354. [PMID: 32968407 PMCID: PMC7501025 DOI: 10.12669/pjms.36.6.1735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objectives: In 2004 Pakistan escalated from ‘low-prevalence’ to ‘concentrated’ phase of HIV epidemic. Despite global decline in HIV incidence since 1997, rate of HIV infections in Pakistan is persistently rising since 1990. Available literature focusses on key populations or localized outbreaks limited by short study duration and regional applicability of results. We studied HIV seroconversion trends over a period of 8 years in a geographically diverse population and evaluated associated risk factors. Methods: A desk review of HIV surveillance data from 2010 to 2017 was carried out at Armed Forces Institute of Pathology. A case was defined as any adult employed in organization ‘X’, initially screened for HIV but later seroconverted on ELISA and western blot. Case-control study was conducted on cases diagnosed in 2017. Age and sex matched controls were identified from same population sub-group. Structured telephonic interviews were conducted and statistical analysis done at 5% margin of error. Results: The annual HIV diagnosis rate remained relatively stable till 2015 (< 40 /100,000/yr) after which it rose sharply to 60/100,000/yr in 2016 .Upward trend continued in 2017 to reach 125/100,000/yr (>200% increase from baseline). Acquisition of HIV was significantly associated with commercial sex activities (OR=9; 95% CI: 1.25-395). Conclusion: HIV seroconversion rates among employees of organization X have increased significantly in the past two years. Unlike HIV outbreaks previously reported from Pakistan, sexual route seems to be the predominant mode of transmission. Focus is mandated on prevention of sexual transmission of HIV at national level as well for all vulnerable populations.
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Affiliation(s)
- Eisha Mansoor
- Eisha Mansoor, MBBS. Armed Forces Post Graduate Medical Institute, Rawalpindi, Pakistan
| | - Naila Azam
- Naila Azam, FCPS (Community Medicine), MCPS (Family Medicine). Armed Forces Post Graduate Medical Institute, Rawalpindi, Pakistan
| | - Saifullah Khan Niazi
- Saifullah Khan Niazi, FCPS (Virology). Armed Forces Institute of Pathology, Rawalpindi, Pakistan
| | - Naveen Sheikh
- Naveen Sheikh, Medical Student, Army Medical College, Rawalpindi, Pakistan
| | - Mirza Amir Baig
- Mirza Amir Baig, MPH, MHM. National Institute of Health, Islamabad - Pakistan
| | - Mansoor Tariq Azim
- Mansoor Tariq Azim, MBBS, FCPS (General Surgery). Military Hospital, Rawalpindi, Pakistan
| | - Nimra Klair
- Nimra Klair, Medical Student, Medical Student, Army Medical College, Rawalpindi, Pakistan
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Siddiqui AR, Ali Nathwani A, Abidi SH, Mahmood SF, Azam I, Sawani S, Kazi AM, Hotwani A, Memon SA, Soomro J, Shaikh SA, Achakzai B, Saeed Q, Simms V, Khan P, Ferrand R, Mir F. Investigation of an extensive outbreak of HIV infection among children in Sindh, Pakistan: protocol for a matched case -control study. BMJ Open 2020; 10:e036723. [PMID: 32213527 PMCID: PMC7170612 DOI: 10.1136/bmjopen-2019-036723] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION In April 2019, 14 children were diagnosed with HIV infection by a private healthcare provider in Larkana district, Sindh province, Pakistan. Over the next 3 months, 930 individuals were diagnosed with HIV, >80% below 16 years, the largest ever outbreak of HIV in children in Pakistan. In this protocol paper, we describe research methods for assessing likely modes of HIV transmission in this outbreak and investigate spatial and molecular epidemiology. METHODS AND ANALYSIS A matched case-control study will be conducted with 406 cases recruited. Cases will be children aged below 16 years registered for care at the HIV treatment centre at Shaikh Zayed Children Hospital in Larkana City. Controls will be children who are HIV-uninfected (confirmed by a rapid HIV test) matched 1:1 by age (within 1 year), sex and neighbourhood. Following written informed consent from the guardian, a structured questionnaire will be administered to collect data on sociodemographic indices and exposure to risk factors for parenteral, vertical and sexual (only among those aged above 10 years) HIV transmission. A blood sample will be collected for hepatitis B and C serology (cases and controls) and HIV lineage studies (cases only). Mothers of participants will be tested for HIV to investigate the possibility of mother-to-child transmission. Conditional logistic regression will be used to investigate the association of a priori defined risk factors with HIV infection. Phylogenetic analyses will be conducted. Global positioning system coordinates of participants' addresses will be collected to investigate concordance between the genetic and spatial epidemiology. ETHICS AND DISSEMINATION Ethical approval was granted by the Ethics Review Committee of the Aga Khan University, Karachi. Study results will be shared with Sindh and National AIDS Control Programs, relevant governmental and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals.
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Affiliation(s)
- Amna R Siddiqui
- Department of Community Health Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | - Apsara Ali Nathwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Syed H Abidi
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | - Syed Faisal Mahmood
- Section of Infectious Disease, Department of Internal Medicine, the Aga Khan University, Karachi, Sindh, Pakistan
| | - Iqbal Azam
- Department of Community Health Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | - Sobiya Sawani
- Department of Community Health Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | - Abdul M Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Infectious Disease Research Laboratory, Department of Pediatrics and Child Health, the Aga Khan University, Karachi, Sindh, Pakistan
| | - Sikander Ali Memon
- Sindh AIDS Control Program, Ministry of Health, Karachi, Sindh, Pakistan
| | - Jamila Soomro
- Public Health Wing, Ministry of Health, Karachi, Sindh, Pakistan
| | - Saqib Ali Shaikh
- Sindh AIDS Control Program, Ministry of Health, Karachi, Sindh, Pakistan
| | | | - Quaid Saeed
- National AIDS Control Program, Islamabad, Pakistan
| | - Victoria Simms
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Palwasha Khan
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Rashida Ferrand
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Fatima Mir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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Mir F, Mahmood F, Siddiqui AR, Baqi S, Abidi SH, Kazi AM, Nathwani AA, Ladhani A, Qamar FN, Soofi SB, Memon SA, Soomro J, Shaikh SA, Simms V, Khan P, Ferrand RA. HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak. THE LANCET. INFECTIOUS DISEASES 2020; 20:362-370. [PMID: 31866326 DOI: 10.1016/s1473-3099(19)30743-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care. METHODS In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ2 tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV. FINDINGS Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions. INTERPRETATION This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies. FUNDING None.
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Affiliation(s)
- Fatima Mir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Faisal Mahmood
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Shehla Baqi
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed Hani Abidi
- Department of Basic and Biological Sciences, Aga Khan University, Karachi, Pakistan
| | - Abdul Momin Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Apsara Ali Nathwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Amerta Ladhani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Farah Naz Qamar
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Bashir Soofi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | - Victoria Simms
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Palwasha Khan
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Rashida Abbas Ferrand
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Tariq U, Mahmood F, Naeem S, Ali S, Abidi SH. Emergence of HIV-1 Unique DG Recombinant Form in Pakistan. AIDS Res Hum Retroviruses 2020; 36:248-250. [PMID: 31547672 DOI: 10.1089/aid.2019.0183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
After the first case of HIV infection in 1987, the number of cases has continuously increased in Pakistan, turning from isolated incidents to outbreaks to the concentrated epidemic. The HIV epidemic in Pakistan is mainly driven by subtype A; however, the overlapping transmission chains facilitate recombination between subtypes and existing circulating recombinants forms (CRFs), leading to the emergence of unique recombinant forms (URFs). In this study, we report the first case of a URF (URF_DG) in a Pakistani HIV-infected patient. Phylogenetic and drug resistance analysis of the patient-derived sequence indicated that Pakistani URF_DG sequence was closely related to the URF_DG sequence reported from the United Kingdom, but had more drug resistance mutations than the U.K. sequence.
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Affiliation(s)
- Uroosa Tariq
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Department of Biochemistry, University of Karachi, Karachi, Pakistan
| | - Faisal Mahmood
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Sadaf Naeem
- Department of Biochemistry, University of Karachi, Karachi, Pakistan
| | - Syed Ali
- Nazarbayev University School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Syed Hani Abidi
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
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11
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Davlidova S, Abidi SH, Ali S. Healthcare malpractice and continuing HIV outbreaks in Pakistan. BMJ Glob Health 2019; 4:e001920. [PMID: 31799002 PMCID: PMC6861107 DOI: 10.1136/bmjgh-2019-001920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/19/2019] [Accepted: 09/21/2019] [Indexed: 11/03/2022] Open
Affiliation(s)
- Salima Davlidova
- Biomedical Sciences, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | | | - Syed Ali
- Biomedical Sciences, Nazarbayev University School of Medicine, Astana, Kazakhstan
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12
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Rouet F, Nouhin J, Zheng DP, Roche B, Black A, Prak S, Leoz M, Gaudy-Graffin C, Ferradini L, Mom C, Mam S, Gautier C, Lesage G, Ken S, Phon K, Kerleguer A, Yang C, Killam W, Fujita M, Mean C, Fontenille D, Barin F, Plantier JC, Bedford T, Ramos A, Saphonn V. Massive Iatrogenic Outbreak of Human Immunodeficiency Virus Type 1 in Rural Cambodia, 2014-2015. Clin Infect Dis 2019; 66:1733-1741. [PMID: 29211835 DOI: 10.1093/cid/cix1071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/01/2017] [Indexed: 12/12/2022] Open
Abstract
Background In 2014-2015, 242 individuals aged 2-89 years were newly diagnosed with human immunodeficiency virus type 1 (HIV-1) in Roka, a rural commune in Cambodia. A case-control study attributed the outbreak to unsafe injections. We aimed to reconstruct the likely transmission history of the outbreak. Methods We assessed in 209 (86.4%) HIV-infected cases the presence of hepatitis C virus (HCV) and hepatitis B virus (HBV). We identified recent infections using antibody (Ab) avidity testing for HIV and HCV. We performed amplification, sequencing, and evolutionary phylogenetic analyses of viral strains. Geographical coordinates and parenteral exposure through medical services provided by an unlicensed healthcare practitioner were obtained from 193 cases and 1499 controls during interviews. Results Cases were coinfected with HCV (78.5%) and HBV (12.9%). We identified 79 (37.8%) recent (<130 days) HIV infections. Phylogeny of 202 HIV env C2V3 sequences showed a 198-sample CRF01_AE strains cluster, with time to most recent common ancestor (tMRCA) in September 2013 (95% highest posterior density, August 2012-July 2014), and a peak of 15 infections/day in September 2014. Three geospatial HIV hotspots were discernible in Roka and correlated with high exposure to the practitioner (P = .04). Fifty-nine of 153 (38.6%) tested cases showed recent (<180 days) HCV infections. Ninety HCV NS5B sequences formed 3 main clades, 1 containing 34 subtypes 1b with tMRCA in 2012, and 2 with 51 subtypes 6e and tMRCAs in 2002-2003. Conclusions Unsafe injections in Cambodia most likely led to an explosive iatrogenic spreading of HIV, associated with a long-standing and more genetically diverse HCV propagation.
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Affiliation(s)
- François Rouet
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Janin Nouhin
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Du-Ping Zheng
- International Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Benjamin Roche
- Unité Mixte de Recherche Institut de Recherche pour le Développement 224, Centre National de la Recherche Scientifique 5290, Université de Montpellier, Maladies Infectieuses et Vecteurs: Ecologie, Génétique, Evolution et Contrôle, Montpellier, France
| | - Allison Black
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sophearot Prak
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Marie Leoz
- Centre National de Référence sur le VIH, Laboratoire Associé, EA2656, Rouen University Hospital, Tours, France
| | - Catherine Gaudy-Graffin
- Centre National de Référence sur le VIH and Institut national de la santé et de la recherche médicale, Unité 966, Tours, France
| | | | - Chandara Mom
- National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, Phnom Penh, Cambodia
| | - Sovatha Mam
- National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, Phnom Penh, Cambodia
| | - Charlotte Gautier
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Gérard Lesage
- Centre National de Référence sur le VIH and Institut national de la santé et de la recherche médicale, Unité 966, Tours, France
| | - Sreymom Ken
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Kerya Phon
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Alexandra Kerleguer
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Chunfu Yang
- International Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - William Killam
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Phnom Penh, Cambodia
| | | | - Chhivun Mean
- National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, Phnom Penh, Cambodia
| | - Didier Fontenille
- Unité Virus de l'Immunodéficience Humaine (VIH)/Hépatites, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Francis Barin
- Centre National de Référence sur le VIH and Institut national de la santé et de la recherche médicale, Unité 966, Tours, France
| | - Jean-Christophe Plantier
- Centre National de Référence sur le VIH, Laboratoire Associé, EA2656, Rouen University Hospital, Tours, France
| | - Trevor Bedford
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Artur Ramos
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Phnom Penh, Cambodia
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Altaf A. Unsafe Injection Practices by Medical Practitioners in South Asia Associated with Hepatitis and HIV Outbreaks. JOURNAL OF INFECTIOLOGY 2018; 1:1-3. [PMID: 39649014 PMCID: PMC7617092 DOI: 10.29245/2689-9981/2018/2.1113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/10/2024]
Affiliation(s)
- Arshad Altaf
- World Health Organization, Western Pacific Region, Manila, Philippines
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14
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Mohamoud YA, Miller FD, Abu-Raddad LJ. Potential for human immunodeficiency virus parenteral transmission in the Middle East and North Africa: An analysis using hepatitis C virus as a proxy biomarker. World J Gastroenterol 2014; 20:12734-12752. [PMID: 25278675 PMCID: PMC4177460 DOI: 10.3748/wjg.v20.i36.12734] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/20/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
The Middle East and North Africa (MENA) region has endured several major events of infection parenteral transmission. Recent work has established the utility of using hepatitis C virus (HCV) as a proxy biomarker for assessing the epidemic potential for human immunodeficiency virus (HIV) parenteral transmission. In this review, we use data on the prevalence of HCV infection antibody (seroprevalence) among general population and high risk population groups to assess the potential for HIV parenteral transmission in MENA. Relatively low prevalence of HCV infection in the general population groups was reported in most MENA countries indicating that parenteral HIV transmission at endemic levels does not appear to be a cause for concern. Nonetheless, there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities. Though there have been steady improvements in safety measures related to parenteral modes of transmission in the region, these improvements have not been uniform across all countries. More precautions, including infection control training programs, surveillance systems for nosocomial infections and wider coverage and evaluation of hepatitis B virus immunization programs need to be implemented to avoid the unnecessary spread of HIV, HCV, and other blood-borne pathogens along the parenteral modes of transmission.
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