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

Pakistan has accumulated substantial evidence on HIV transmission, but the continuing challenge is to turn surveillance, treatment and prevention into a coordinated response that reaches people and communities in time.

Prof Dr Muhammad Rafiq Khanani

The gap between knowing and acting

Pakistan has nevertheless made progress in one visible area: the expansion of free antiretroviral therapy. The country had approximately 95 ART centres by 2025. But the number of centres can create an impression of progress that the treatment cascade does not necessarily support. The more meaningful questions are whether people living with HIV know their status, whether those diagnosed begin treatment, whether they remain on treatment and whether they achieve viral suppression.

An ART centre is of limited value to someone who does not know they are infected, cannot reach the service, drops out of treatment or never receives the viral-load monitoring needed to establish whether treatment is working.

That gap between the visible system and the hidden epidemic may be Pakistan’s most serious vulnerability.

                                                                                                Source: CDC-HIV Sindh

The epidemic itself has also changed. What began as sporadic or imported infection moved through outbreaks associated with people who inject drugs and expanded among key populations. It subsequently acquired a broader sexual bridge through spouses and partners, while mother-to-child transmission, healthcare-associated transmission and paediatric outbreaks have added further dimensions. The result is no longer adequately described by the old shorthand of an epidemic confined to “high-risk groups”.

The implications are profound

Pakistan needs a national HIV response that connects federal leadership with provincial implementation and district-level surveillance. A National HIV Acceleration Plan for 2026–2030, as proposed in the source document, would need measurable annual targets and a national dashboard capable of showing the entire treatment cascade — from estimated people living with HIV through diagnosis and treatment to retention, viral suppression, new infections and deaths.

But national plans will remain paper exercises if the epidemic cannot be seen at district level.

Provincial and district health systems need to know where undiagnosed infections are concentrated, where new diagnoses are emerging and whether transmission is associated with particular communities or healthcare settings. District-level coordination would have to bring public health, laboratories, ART services, infection control, maternal health, blood transfusion, community organisations and healthcare regulators into the same conversation.

Healthcare safety deserves particular attention

Pakistan’s experience with paediatric and healthcare-associated HIV outbreaks makes it impossible to separate HIV prevention from infection prevention and control. Safe injections, sterilisation, phlebotomy, dentistry, dialysis, surgery, infusion practices and blood transfusion are not peripheral concerns. They are part of HIV prevention itself. An unexplained HIV infection in a child whose mother is HIV-negative, for example, should raise an immediate public-health question about possible healthcare-associated transmission.

The same principle applies to blood safety. Quality-assured screening, donor traceability and haemovigilance need to be treated as essential components of HIV control, while a new infection in a repeatedly transfused patient should prompt an appropriate trace-back investigation.

At the other end of the system lies the community

NGOs and community-based organisations are often best placed to reach people whom conventional health services struggle to reach, including people who inject drugs, transgender people, sex workers, prisoners and partners of people living with HIV. Their role, however, should not end with awareness activities. Their effectiveness ultimately has to be judged by whether people are reached, tested, diagnosed, linked with treatment and retained in care.

Drug dependence must similarly be approached as a public-health issue rather than through punishment alone. HIV testing, sterile injecting equipment, opioid agonist treatment, ART and hepatitis services need to be connected for people who inject drugs. Driving vulnerable populations further underground only makes HIV harder to detect and control.

Maternal and child health offers another opportunity that Pakistan cannot afford to miss. HIV testing during antenatal care, prompt treatment of infected pregnant women, infant prophylaxis and early infant diagnosis can prevent transmission to the next generation.

Laboratories, too, can become part of an early-warning system. An unusual cluster of HIV-positive children from the same locality, for instance, should not remain an isolated clinical observation. It should prompt an epidemiological response, with molecular epidemiology increasingly complementing conventional investigation where appropriate.

Perhaps the most important change, however, has to occur in how HIV is discussed.

For years, stigma has allowed HIV to be presented as a disease belonging to “immoral” or supposedly distant populations. Such language does not contain an epidemic; it conceals it. A person with an exposure can acquire HIV regardless of assumptions about morality or social identity. Testing can be confidential, treatment is available, and effective treatment can prevent sexual transmission.

The media, religious leaders and community leaders therefore have a role that goes beyond awareness campaigns. They can either reinforce fear and moral judgement or help create an environment in which people seek testing and treatment before transmission continues silently.

The author is President Infection Control Society Pakistan

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

Illustrations: AI-generated