A pediatric HIV outbreak in Pakistan.

Background: Following reports of an outbreak of HIV infection among children in Larkana District, Pakistan, an international team investigated the extent and cause of the outbreak between April and June 2019. Aims: To investigate the incidence of HIV among children in Larkana District, Pakistan and describe the distribution of cases by time, place and person. Methods: Self-referred persons were tested for HIV using the national testing protocol. Local epidemiology of HIV was reviewed to generate hypotheses. An infection prevention and control (IPC) team conducted site visits and reviewed IPC practices. Results: Between 25 April and 27 June 2019, a total of 30 191 persons were tested for HIV in Larkana District, and 876 of them tested positive. Of those who tested positive, 719 (82%) were children aged <15 years. Traditional skin piercing procedures and transmission from high-risk populations to children were ruled out during the investigation. Informative interviews with parents or guardians of a convenience sample of 211 children aged <15 years showed that 99% of children had an injection or infusion for medical treatment within the past 12 months. Our investigation identified lack of HIV prevalence data for the general population including tuberculosis patients and those who attended antenatal care services. Conclusions: Investigations indicate that unsafe healthcare practices in formal and informal healthcare settings as the most likely cause of the 2019 outbreak of HIV infection in Larkana, Pakistan. Measures should be taken to improve IPC practices at the facility level, especially in pediatric and antenatal care clinics.

Acceptability and feasibility of intra-peer and social media approach for HIV self-testing among men who have sex with men in Karachi: lessons from a pilot study.

OBJECTIVE: To use a peer-to-peer and social media approach to reach out to men who have sex with men (MSM) and to distribute human immunodeficiency virus self-testing kits among them in an urban setting. METHODS: The cross-sectional, pilot study was conducted by a community-based organisation in Karachi from November 2020 to February 2021, and comprised men aged 18 years or above who have sex with men. The subjects were provided one human immunodeficiency virus self-testing kit (HIVST) per person by trained outreach workers. It was an oral fluid-based kit. Data related to demographics, behavioural patterns and human immunodeficiency virus testing detail was collected on a structured questionnaire with some open-ended questions. The analysis of qualitative data was done manually, using content analysis technique in which all common responses were grouped that led to the generation of themes. RESULTS: There were 150 male subjects with mean age 31.5+/-8.7 years. Overall, 62(41.3%) subjects had received up to 15 years of formal education, 94(62.6%) were first-time testers; 139(92.7%) performed the test at home; 11(7.3%) used the kit at the community-based organisation's office. In terms of results, 1(0.7%) participant had a reactive result which was later confirmed as positive for human immunodeficiency virus. Of the total, 145(96.6%) participants found the instructions and the kit easy to use on their own, 83(55.3%) preferred a social media-based approach, and 68(45.3%) preferred the peer-to-peer approach. CONCLUSIONS: The HIVST was found to be acceptable among men who have sex with men, while peer-led and social media approaches seemed to be an effective method of information dissemination.

Acceptability and feasibility of HIV self-testing among transgender people in Larkana, Pakistan: Results from a pilot project.

BACKGROUND: HIV self-testing (HIVST) is an innovative HIV testing approach that effectively reaches those who do not otherwise test, including key populations (KPs). Despite potential benefits, HIVST is not currently implemented in Pakistan. The high risk of HIV among transgender (TGs) persons is among the highest risk group for HIV in Pakistan, yet knowledge of HIV status remains low in this key population group. We conducted a pilot project to assess the acceptability and feasibility of distributing HIVST to TGs in Larkana. METHODS: Eligible participants were 18 years or above and self-identified as transgender ("hijra"). One oral fluid HIVST kit per person was distributed free of cost in the community by trained transgender peer outreach workers (ORW). Participants could request a demonstration of the HIVST procedure before performing self-testing which was provided by the trained ORW. Demographic characteristics of participants were collected. The ORW followed up with phone calls two days later to record if HIVST kits were used, the results, and whether assistance was required. RESULTS: Between November 2020 and February 2021, 150 HIVST kits were distributed to eligible TGs. The average age of participants was 25.5 years (standard deviation: 7.0). Over a third (52, 34.7%) had no formal education, while (16, 10.6%) had attended at least five years of schooling. Over one-third (58, 38.6%) of participants were first-time testers. One hundred and thirty-nine (92.7%) participants reported their results within two days. For the remaining 11 participants, ORWs had to contact them. All participants reported using HIVST kits within three days. A majority (141, 94%) used the kit in their homes, and the remaining nine (6%) used it at the community-based organization's office. Overall, a small proportion (11, 7.3%) of participants requested a demonstration of the test procedure before performing HIVST. Four (2.7%) participants who had performed unsupervised self-tests reported reactive HIVST results; all were linked to treatment within five working days once their HIV result was confirmed. The majority (136, 90.6%) of participants felt that self-testing was easy to perform independently, and 143 (95%) reported that they would recommend HIVST to their peers. CONCLUSION: HIVST is acceptable among TGs and identified by first-time testers as undiagnosed infections. Peer-led distribution appears to be a feasible approach for implementation in this setting. HIVST should be considered for routine implementation and scale up to reduce testing gaps among Pakistan's key population, particularly TGs.