Pakistan’s HIV wake-up call: The cost of waiting until 2030 — Part I

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While the global HIV epidemic is declining, Pakistan is moving in the opposite direction. Four decades after the first locally acquired infections were documented, the country faces a widening gap between what it knows about the epidemic and what it is doing to contain it

By Prof Dr Muhammad Rafiq Khanani

Pakistan has lived with HIV (Human immunodeficiency virus) for almost four decades. Yet the country’s present challenge is no longer simply to understand how the virus spreads. It is to confront why, despite years of surveillance, treatment programmes and accumulated evidence, transmission continues to expand.

The first locally acquired HIV infections were documented in Karachi in the mid-1980s. The early report described four infected people, including a professional blood donor and a family in which HIV was transmitted from a drug-using husband to his wife and subsequently to their infant. Even at that stage, the warning signs were clear: unsafe blood, injecting drug use, sexual transmission and mother-to-child transmission could all become part of Pakistan’s HIV story.

For some years, however, the picture remained partly obscured by infections identified among Pakistanis returning from abroad. A Karachi study covering 1986–1992 found that about two-thirds of HIV-positive people in its series were foreigners, expatriates or Pakistanis settled abroad.

ST file photo

A particularly alarming episode was reported from the SITE area in 2025. Cases were reported in July and August, and an ART centre was functioning by November 2025. At least 18 children, reportedly aged between about one and nine years and treated at the hospital, were subsequently found to be HIV-positive. The episode raised serious questions about whether surveillance, infection-control audits and timely investigation had been initiated at the required scale. More broadly, the danger is that failure to identify and openly investigate individual cases can allow transmission clusters to grow before they become visible as a public-health emergency.

That pattern eventually changed as locally acquired infections increased, particularly among vulnerable populations. By the early 2000s, Pakistan could no longer view HIV principally as an imported or sporadic sexually transmitted infection. Transmission networks were becoming established among people who inject drugs, men who have sex with men, transgender people, sex workers, spouses and children born to infected mothers.

How Pakistan got here

Pakistan did respond by developing one of the region’s significant second-generation HIV surveillance systems. The Integrated Behavioural and Biological Surveillance system, piloted in 2004–05 in Karachi and Rawalpindi, and subsequently expanded nationally, generated evidence about the size, distribution, behaviour and HIV prevalence of key populations.

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The findings were increasingly difficult to ignore. By the fourth round, surveillance in 20 cities estimated HIV prevalence at 37.8 per cent among people who inject drugs, compared with 7.2 per cent among transgender sex workers, 3.1 per cent among male sex workers and 0.8 per cent among female sex workers. Later rounds continued to update the surveillance picture, with Round VI covering key populations and prisoners in 31 selected districts.

The uncomfortable lesson is that Pakistan has not necessarily suffered from a complete absence of evidence. It has repeatedly produced evidence showing where transmission is occurring. The greater failure has been translating that evidence into prevention and treatment services on a scale large enough, and for long enough, to alter the course of the epidemic. Besides, there is another weakness: the limited and delayed sharing of surveillance information with the public, media and other stakeholders.

There was a time when surveillance was more closely connected with services. Outreach programmes provided HIV education, testing, condoms, sterile needles and syringes, referrals and other preventive support to populations that often remained distant from conventional healthcare because of stigma, discrimination or criminalisation. But coverage was never sufficient, and prevention did not expand consistently with the changing epidemic.

Recent programme assessments have continued to identify familiar weaknesses: fragmented governance, poor coordination between national and provincial programmes, inadequate data integration, outdated prevalence information, limited effectiveness of testing and prevention, insufficient antiretroviral treatment coverage and treatment drop-out.

This is why HIV can no longer be treated simply as the responsibility of a specialised health programme. Its determinants reach into blood safety, healthcare practices, drug dependence, maternal and child health, community behaviour, stigma, regulation and public financing.

The author is President Infection Control Society Pakistan

(To be continued, with the courtesy of Social Track, Karachi)