Prevalence of HIV among pregnant women in three HIV-affected districts in Sindh, Pakistan.

OBJECTIVE: To conduct a community-based cross-sectional survey to determine the prevalence of human immunodeficiency virus (HIV) among pregnant women in taluka Ratodero, Larkana, and two adjacent talukas: Sajawal, district Kambar Shahdadkot and Garhi Yasin, district Shikarpur. METHODS: The study was conducted among pregnant women in the three talukas of rural Sindh: Ratodero, Garhi Yasin, and Sajawal, from October 16, 2020 - December 23, 2020. A total of 1,157 pregnant women were interviewed at their homes and tested using the AlereTM HIV Combo rapid finger prick test. The study captured women's sociodemographic, economic, and health characteristics, including age, education, employment, number of children, home or hospital delivery, antenatal care use, antenatal trimester, history of blood transfusion, and HIV test result. Descriptive statistics were calculated: percentages for categorical variables and mean ± standard deviation (SD) for continuous variables. RESULTS: It was found that 0.35% (4/1,157) of women were HIV-positive, of which 3 were in Ratodero, Larkana, and 1 was in Garhi Yasin, Shikarpur. The average age of women was 28.7 ± 4.0 years. Most of the women (n=1067; 92.2%) did not attend a school, and 99.0% (n=1145) had never had a formal job. The average gestational age was 7.6 (±2.2) months. More than three-quarters of the women participating in the study (n=894; 77.3%) were not registered with a formal healthcare facility for antenatal care. CONCLUSIONS: Considering several HIV sub-epidemics in Larkana in the past decade, HIV infection among pregnant women has remained low in Larkana and adjacent districts.

Risk Factors for Loss to Follow-Up among People Who Inject Drugs in a Risk Reduction Program at Karachi, Pakistan. A Case-Cohort Study.

INTRODUCTION: Retention of male people who inject drugs (PWIDs) is a major challenge for harm reduction programs that include sterile needle/syringe exchange in resource-limited settings like Pakistan. We assessed the risk factors for loss to follow-up among male PWIDs enrolled in a risk reduction program in Karachi, Pakistan. METHODS: We conducted a prospective cohort study among 636 HIV-uninfected male PWIDs enrolled during March-June 2009 in a harm reduction program for the estimation of incidence rate. At 24 months post-enrollment, clients who had dropped out of the program were defined as lost to follow-up and included as cases for case-cohort study. RESULTS: The median age of the participants was 29 years (interquartile range: 23-36). Active outreach accounted for 76% (483/636) of cohort recruits. Loss to follow-up at 24 months was 25.5% (162/636). In multivariable logistic regression, younger age (AOR: 0.97, 95% CI: 0.92-0.99, p = 0.028), clients from other provinces than Sindh (AOR: 1.49, 95% CI: 1.01-2.22, p = 0.046), having no formal education (AOR: 3.44, 95% CI: 2.35-4.90, p<0.001), a history of incarceration (AOR: 1.68, 95% CI: 1.14-2.46, p<0.008), and being homeless (AOR: 1.47, 95% CI: 1.00-2.19, p<0.049) were associated with loss to follow-up. CONCLUSIONS: Our cohort retained 74.5% of male PWIDs in Karachi for 24 months. Its loss to follow up rate suggested substantial ongoing programmatic challenges. Programmatic enhancements are needed for the highest risk male PWIDs, i.e., younger men, men not from Sindh Province, men who are poorly educated, formerly incarcerated, and/or homeless.

Ethnic disparities in routine immunization coverage: a reason for persistent poliovirus circulation in Karachi, Pakistan?

Karachi is the only mega city in the world with persistent poliovirus transmission. We determined routine childhood immunization rates in Karachi and identified predictors of vaccine completion. A population-based cross-sectional survey was conducted in Karachi between August and September 2008. Data on demographics, socioeconomic, and DTP3 vaccination status in children 12 to 23 months old were collected. Logistic regression was used to identify predictors of vaccination completion. Overall, 1401 participants were approached; 1391 consented to participate. Of these, 1038 (75%) were completely vaccinated. Punjabi families had the highest DTP3 coverage (82%), followed by Urdu-speaking families (79%). Pashtun (67%) and Bengali (48%) families had the lowest vaccine coverage. Children of mothers with ≥ 12 years of schooling (OR = 25.4; 95% CI = 5.7-113.1) were most likely to be vaccinated. A quarter of study participants were unvaccinated. Targeted strategies for boosting DTP3 rates in communities with low immunization coverage are essential for polio eradication in Karachi.

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless.

BACKGROUND: The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted. METHODS: We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion. RESULTS: Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3-14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (AR  = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04). CONCLUSIONS: Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009-2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

Size estimation, HIV prevalence and risk behaviours of female sex workers in Pakistan.

OBJECTIVE: To provide size estimation and to determine risky behaviours and HIV prevalence among female sex workers in Pakistan, which has progressed from a low to concentrated level of HIV epidemic. METHODS: A cross-sectional study (geographic mapping and integrated behavioural and biological survey-IBBS) was conducted between August 2005 to January 2006 in Karachi, Hyderabad and Sukkur. A detailed questionnaire and dry blood spot (DBS) specimen for HIV testing were collected by trained interviewers after informed consent. The study was ethically approved by review boards in Canada and Pakistan. RESULTS: About 14,900 female sex workers were estimated to be functional in Sindh. A total of 1158 of them were interviewed for the study. Average age of sex workers was 27.4 +/- 6.7 years, and the majority 787 (67.9%) were married, and uneducated 764 (65.9%). Sindhi (26.4%) was the predominant ethnicity. Mean number of paid clients was 2.1 +/- 1.2. three workers were confirmed HIV positive (0.75%, 95 percent CI 0.2-2.2%) from Karachi. Condom use at last sexual act was highest (68%) among brothel-based workers from Karachi, and the lowest in Sukkur where only 1.3% street-based workers reported using a condom at last sexual act. Overall use of illicit drugs through injections was negligible. CONCLUSION: HIV prevalence among female sex workers in Sindh, Pakistan is low but risky behaviours are present. Well organised service delivery programmes can help promoting safer practices.

Comparing risk factors of HIV among hijra sex workers in Larkana and other cities of Pakistan: an analytical cross sectional study.

BACKGROUND: In 2005, Pakistan was first labeled as a country with concentrated epidemic of Human Immunodeficiency Virus (HIV). This was revealed through second generation surveillance conducted by HIV/AIDS Surveillance Project (HASP). While injection drug users (IDUs) were driving the epidemic, subsequent surveys showed that Hijra (transgender) sex workers (HSWs) were emerging as the second most vulnerable group with an average national prevalence of 6.4%. An exceptionally high prevalence (27.6%) was found in Larkana, which is a small town on the right bank of river Indus near the ruins of Mohenjo-Daro in the province of Sindh. This paper presents the risk factors associated with high prevalence of HIV among HSWs in Larkana as compared to other cities of the country. METHODS: Data were extracted for secondary analysis from 2008 Integrated behavioral and biological survey (IBBS) to compare HSWs living in Larkana with those living in other cities including Karachi and Hyderabad in Sindh; Lahore and Faisalabad in Punjab; and Peshawar in Khyber Pakhtunkhwa provinces. After descriptive analysis, univariate and multivariate analyses were performed to identify risk factors. P value of 0.25 or less was used to include factors in multivariate analysis. RESULTS: We compared 199 HSWs from Larkana with 420 HSWs from other cities. The average age of HSWs in Larkana was 26.42 (±5.4) years. Majority were Sindhi speaking (80%), uneducated (68%) and unmarried (97%). In univariate analysis, factors associated with higher prevalence of HIV in Larkana included younger age i.e. 20-24 years (OR: 5.8, CI: 2.809-12.15), being unmarried (OR: 2.4, CI: 1.0-5.7), sex work as the only mode of income (OR: 5.5, CI: 3.70-8.2) and longer duration of being involved in sex work 5-10 years (OR: 3.3, CI: 1.7-6.12). In multivariate logistic regression the HSWs from Larkana were more likely to lack knowledge regarding preventive measures against HIV (OR 11.9, CI: 3.4-41.08) and were more prone to use of alcohol during anal intercourse (OR: 6.3, CI: 2.77-17.797). CONCLUSION: Outreach programs focusing on safer sexual practices and VCT are urgently needed to address the upsurge of HIV among HSWs in Larkana.

Women trafficking: causes, concerns, care!

Pakistan is both a country of origin and destination as far as women trafficking is concerned. Poverty, gender discrimination, lack of education, and ignorance about legal rights are some of the underlying causes. Available data suggest several areas of concern, like, for instance: direct health effects, maladaptive coping leading to the use of illicit drugs, and inaccessibility to healthcare facilities. Therefore, numerous interventions would be required at three levels: the prevention of trafficking, the protection of victims and the prosecution of the traffickers.

Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based randomized-controlled trial in Karachi, Pakistan.

BACKGROUND: In Pakistan, only 59-73% of children 12-23 months of age are fully immunized. This randomized, controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates. METHODS: Three hundred and sixty-six mother-infant pairs, with infants aged ≤ 6 weeks, were enrolled and randomized into either the intervention or control arm between August - November 2008. The intervention, administered by trained community health workers, consisted of three targeted pictorial messages regarding vaccines. The control group received general health promotion messages based on Pakistan's Lady Health Worker program curriculum. Assessment of DPT/Hepatitis B vaccine completion (3 doses) was conducted 4-months after enrollment. A Poisson regression model was used to estimate effect of the intervention. The multivariable Poisson regression model included maternal education, paternal occupation, ownership of home, cooking fuel used at home, place of residence, the child's immunization status at enrollment, and mother's perception about the impact of immunization on child's health. RESULTS: Baseline characteristics among the two groups were similar. At 4 month assessment, among 179 mother-infant pairs in the intervention group, 129 (72.1%) had received all 3 doses of DPT/Hepatitis B vaccine, whereas in the control group 92/178 (51.7%) had received all 3 doses. Multivariable analysis revealed a significant improvement of 39% (adjusted RR = 1.39; 95% CI: 1.06-1.81) in DPT-3/Hepatitis B completion rates in the intervention group. CONCLUSION: A simple educational intervention designed for low-literate populations, improved DPT-3/Hepatitis B vaccine completion rates by 39%. These findings have important implications for improving routine immunization rates in Pakistan.

Dynamic contrast enhanced MRI breast for lesion detection and characterization with histopathological co relation: preliminary experience at tertiary care hospital.

OBJECTIVE: To determine the morphological and enhancement characteristics significantly associated with malignant breast lesions on dynamic contrast enhanced MRI by considering the histopathological findings as a gold standard. METHODS: A retrospective analysis was performed on 70 patients who underwent MRI breast during the study period because of suspicious mammographic abnormalities. MR imaging was performed on 1.5 tesla machine with dynamic contrast enhancement by using dedicated breast coil. MR Images of breast were evaluated on a workstation and reported on the basis of morphological appearance of lesion and time activity curves. Histopathological analysis of the lesion was done either after mastectomy or biopsy. About 66 MR suspicious lesions were biopsied in 58 patients. RESULTS: Total number of MRI breast performed from Jan 2007-June 2009 for suspicious abnormality was 70. Histopathology of 66 lesions was available in 58 patients. Twelve patients were lost to follow. On multiple logistic regression analysis, lesions with irregular margins and strong heterogeneous enhancement were associated with higher odd of malignancy than lesions with smooth margins and homogenous enhancement. The next most important feature was the qualitative assessment of kinetic curve. Type 111 and 11 curves showed significant association with malignancy with higher odd values and 95% CI. The sensitivity, specificity, positive and negative predictive values of MRI for breast lesions was found to be 94%, 85%, 90%, and 82% respectively. Overall accuracy of MRI breast was 90%. CONCLUSION: On dynamic contrast enhanced MR imaging morphological appearance of lesion and qualitative assessment of time activity curves are two major factors for differentiation of breast lesion as benign or malignant.

Knowledge, attitudes and practices (KAP) regarding sexuality, sexual behaviors and contraceptives among college/university students in Karachi, Pakistan.

OBJECTIVE: To assess the knowledge, attitudes and practices regarding sexuality, high risk sexual behaviors and methods of contraception, among college/university students of Karachi, Pakistan. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Higher Education Commission-recognized government and private colleges/universities in Karachi from 2005-2006. METHODOLOGY: Two colleges/universities were randomly selected from each category i.e. government medical, government non-medical and private medical and non-medical colleges/universities. Three stage cluster sampling was employed to draw a representative sample of students. A self administered questionnaire was used to elicit information on knowledge, attitudes and practices regarding high risk sexual behaviors, methods of contraception and sources to obtain information about sexual issues. RESULTS: A total of 957 students were interviewed. They comprised 542 (56.6%) males and 415 (43.4%) females with mean age of 21 ± 1.8 years. Bivariate analysis showed that students enrolled in medical colleges/universities were less likely to watch adult films (O.R. 0.7, CI; 0.5-0.9) to acquire sex related knowledge and go out on dates (O.R. 0.6, CI; 0.4- 0.8). Similarly, medical students were less likely to consider contraception as being against Islamic teachings (O.R. 0.7, CI; 0.5-0.9). CONCLUSION: The curricula of non-medical studies at undergraduate level should include education regarding sexual health and contraception.

Measles susceptibility in children in Karachi, Pakistan.

Measles, despite being vaccine preventable is still a major public health problem in many developing countries. We estimated the proportion of measles susceptible children in Karachi, the largest metropolitan city of Pakistan, one year after the nationwide measles supplementary immunization activity (SIA) of 2007-2008. Oral fluid specimens of 504 randomly selected children from Karachi, aged 12-59 months were collected to detect measles IgG antibodies. Measles antibodies were detected in only 55% children. The proportion of children whose families reported receiving a single or two doses of measles vaccine were 78% and 12% respectively. Only 3% of parents reported that their child received measles vaccine through the SIA. Among the reported single dose measles vaccine recipients, 58% had serologic immunity against measles while among the reported two dose measles vaccine recipients, 64% had evidence of measles immunity. Urgent strengthening of routine immunization services and high quality mass vaccination campaigns against measles are recommended to achieve measles elimination in Pakistan.

Potential benefits and perceived need for health promoting hospitals in Pakistan: a healthcare stakeholder's perspective.

OBJECTIVES: To explore perceptions of healthcare stakeholders' about health promoting hospitals, potential benefits and need in Pakistan. METHODOLOGY: A qualitative exploratory study was conducted between July-August 2007. The data was collected through key-informant (KI) interviews and focus group discussions (FGD) with purposively selected hospital administrators, healthcare providers, health policy makers, and UN-donor agency representatives. The thematic analysis was done using QSR NVivo 2.0; and nodes representing themes were generated. RESULTS: The study participants perceived health promotion, a concept synonymous to health education. Those participants with public health background were better able to relate their perceptions to a more holistic view of health promotion; than those without public health background. Participants largely revealed HPH to benefit not only patients, but also community, hospital staff and hospitals at large. HPH transition was also perceived as 'opportunistic step' for controlling triple burden of diseases, curtailing morbidity and mortality toll, and 'sole answer' to promote population health, and wellbeing. Given the view, HPH was strongly recommended as "Need of the hour" for Pakistan. CONCLUSION: The HPH settings would bring positive change in the healthcare delivery system, by empowering patients and local community. Technical trainings on health promotion for healthcare providers, constant policy dialogue, political will and support from community stakeholders will further strengthen the scope of health promoting hospitals in Pakistan.

Father's support and literacy--factors associated with child mortality in Gambat, Sindh-Pakistan.

OBJECTIVES: To determine Under Five Mortality Rate (U5MR) in Gambat and to identify causes of and factors associated with it. METHODS: The study was conducted in taluka Gambat of Sindh, Pakistan from December 2002 to August 2003. The sample of at least 510 mothers was needed to capture expected 1020 live births. We interviewed mothers to elicit information about live births in the past five years, under-five mortality and its cause. Additionally, the mothers were also asked about their mobility and availability of husband's support in child's rearing, other than economic support. Approval was sought from Aga Khan University's Ethical Committee. Pre structured questionnaire was used. Data were double entered, validated and cleaned using Epi-Info 6 and analysed with Statistical Package for Social Sciences (SPSS) version 11.5. RESULTS: We included 647 mothers, who reported 997 births in the past five years. The reported number of deaths was 169, with the estimated U5MR of 170/1000 live births/year. The five major causes of mortality were tetanus (17.8%), diarrhoea (11.8%), measles (6.5%), delivery related morbidities (6.5%) and Acute Respiratory Infections (4.5%). Fever was identified as a cause by 19.1% mothers. About 20% did not know the cause of death. The regression analysis showed father's literacy level (AOR 1.8, 95% CI 1.1-2.8) and father's support in child rearing (AOR 5.6, 95% CI 3.6-8.6) as factors significantly associated with mortality. CONCLUSION: Increasing education among parents in rural areas like Gambat is important to reduce child mortality. Father's involvement in child rearing can play a role.

Tawana project-school nutrition program in Pakistan--its success, bottlenecks and lessons learned.

Tawana Pakistan Project, a multifaceted pilot project (Sept. 2002 to June 2005) was funded by the Government of Pakistan to address poor nutritional status and school enrollment of primary school age girls. The core strategy was to create safe environment empowering village women to take collective decisions. Through reflective learning process women learnt to plan balanced menus, purchase food, prepare and serve a noon meal at school from locally available foods at nominal costs (USD 0.12/child). Aga Khan University partnered the government for the design, management, monitoring and evaluation of the project, 11 NGO's facilitated implementation in 4035 rural government girls' schools. Training was provided to 663 field workers, 4383 community organizers, 4336 school teachers and around 95 thousand rural women. Height and weight were recorded at baseline and every 6 months thereafter. Wasting, underweight and stunting decreased by 45%, 22% and 6% respectively. Enrollment increased by 40%. Women's' ability to plan balanced meals improved and >76% of all meals provided the basic three food groups by end of project. Government bureaucracy issues, especially at the district level proved to be the most challenging bottlenecks. Success can be attributed to synergies gained by dealing with nutrition, education and empowerment issues simultaneously.

Eight key household practices of integrated management of childhood illnesses (IMCI) amongst mothers of children aged 6 to 59 months in Gambat, Sindh, Pakistan.

OBJECTIVE: To determine Knowledge, Attitudes and Practices (KAP) regarding eight key integrated management of childhood illness (IMCI) suggested practices and the association of these key practices with stunting as outcome. METHODS: Sampling proportionate to sub-population sizes was employed to ensure representation from all the Union Councils of taluka Gambat-Sindh. RESULTS: Low female education and mobility show the status of child's first care provider in a typical rural community. Few women knew about giving more food to a child suffering from diarrhoea. Moreover, very few exclusively breastfed their children for first 4-6 months, got their children completely immunized, washed hands before cooking and serving meals and boiled water before utilizing it for drinking purpose. Multiple logistic regression analysis showed that children of mothers, who knew the importance of vaccination, obtained antenatal checkups, exclusively breastfed the last child, washed hands before serving and cooking meals were less likely to be stunted. Similarly, children from households where mothers received husband support in child rearing, and where no child less than five years suffered from diarrhoea in the past one year, were less likely to be stunted. CONCLUSIONS: Without improving education level of females in rural communities, it would be difficult to educate and empower the first care provider of child. However, as an interim strategy, educational messages regarding a limited number of key practices should be disseminated).

Latent activity of curcumin against leishmaniasis in vitro.

In this study the anti-proliferative effect of curcumin (curcuma longa) that is the active ingredient of ground dried rhizome has been studied against three local and three reference leishmanial strains, Leishmania major, Leishmania tropica and Leishmania infantum (Pakistani isolate). Curcumin has shown an average IC50 of 5.3 microM against promastigotes of various leishmanial strains which is much lower as compared with pentamidine that is one of the basic treatments against leishmaniasis. The main draw back attributed to these assays performed on promastigotes is the heterogeneity of results compared with those obtained with intracellular amastigotes or with in vivo effect. We also tested activity of curcumin against axenic amastigote like cells (AALC) of L. major strain (MHOM/PK/88/DESTO). Curcumin proves to be far more potent then pentamidine against AALC which further strengthens the fact about its leishmaniacidal activity.