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.

Index testing among HIV-positive patients is feasible and successful in identifying additional HIV infections in Pakistan.

OBJECTIVE: To assess the feasibility of index testing approach to test the parents and siblings of human immunodeficiency virus (HIV)-positive children, and identify HIV-positive individuals. METHODS: The study was conducted at Ratodero, Pakistan. Study participants were enrolled from September 2019 to February 2020. The list of HIV-positive persons was provided by the Sindh AIDS Control Programme. Families of 706 HIV-positive persons were approached and all of them agreed to participate. The first test was performed by trained outreach workers. All those with a reactive first test were transported to the nearest health facility for further testing and confirmation. Mothers and siblings were tested at home while additional visits were carried out to reach the fathers. RESULTS: A total of 1766 persons were tested through HIV index testing. Biological siblings accounted for 81% of the contacts. We were able to test 413/463 (89.2%) mothers, 232/413 (56.2%) fathers and 1121/1392 (80.5%) siblings. Out of these, 7 mothers (1.7%) and 22 siblings (2.0%) were confirmed to be HIV-positive, while no one was found to be positive among the fathers. The overall HIV prevalence was 1.6% (29/1766). All HIV-positive persons were guided for treatment and care. CONCLUSIONS: Results indicate that index-testing approach is feasible in Pakistan to expand HIV testing services through home visits.

Is Pakistan at the cusp of an ART resistance?

Only 10% of HIV positive individuals in Pakistan are receiving anti-retroviral therapy (ART) and the dropout rate from HIV treatment is extremely high. This short report attempts to highlight the risk of ART resistance. Pakistan National AIDS Control Programme's website reports 15,390 HIV positive persons receiving ART out of which 4,697 (30.5%) are people who inject drugs (PWIDs) among whom HIV prevalence is reported to be 38.4%. In the two large provinces of the country (Punjab and Sindh) with more than 90% burden of HIV, ART was initiated in 2,807 patients between April and September 2018, out of these 37% were lost to follow up. Many patients have cited issues related to quality of service at the ART centres as one of the reasons to not revisiting the treatment centres. HIV planners in Pakistan urgently need to make a new strategy and improve not only the quality of services but also increase the number of HIV positive persons receiving ART.

Hepatitis C elimination in Pakistan is a distant dream unless government controls the health sector.

The World Health Organisation (WHO) has set an ambitious target to eliminate hepatitis C virus (HCV) by 2030. Pakistan is one of the focused countries because of the high prevalence of HCV. The prices of direct-acting antiviral drugs(DAA)have significantly reduced to between 11-25 dollars for a month's treatment. To achieve the 2030 elimination target, Pakistan has to provide treatment to one million HCV-infected patients every year, beginning from 2018. This short report highlights a key barrier to achieve this target,i.e. the unsafe practices by regulated and unregulated healthcare delivery system comprising trained and untrained healthcare providers who can continue to churn out new patients with their unsafe healthcare practices and increase the possibility of reinfection in those who have been treated. Only the government has the power and authority to regulate and control the healthcare delivery system. Elimination of Hepatitis in Pakistan will remain a distant dream unless the healthcare delivery system is tamed.

Injection practices in 2011-2015: a review using data from the demographic and health surveys (DHS).

BACKGROUND: Reuse of injection devices to give healthcare injections decreased from 39.8 to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015. METHODS: We searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004-2010 and 2011-2015. RESULTS: Since 2011, 40 of 92 countries (43%) that conducted DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data in 2004-2010 and 2011-2015, 69% improved in terms of safety. The annual number of unsafe injections reduced in 81% of countries. In Pakistan, the number of unsafe injections was the highest and did not decrease between 2006 and 2012. CONCLUSIONS: Injection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular still faces unsafe practices that are not improving. Further efforts are needed to eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.

Geographical and temporal variation of injection drug users in Pakistan.

OBJECTIVES: We describe the characteristics of injecting drug users (IDU) in Pakistan in 2006 and 2011, and assess the heterogeneity of IDU characteristics across different cities and years as well as factors associated with HIV infection. METHODS: Cross-sectional, integrated behavioural-biological surveys of IDU were conducted in 10 cities across Pakistan in 2006 and 2011. Univariate and multivariable analyses were used to describe the differences in HIV prevalence and risk behaviours between cities and over time. RESULTS: Large increases in HIV prevalence among injection drug users in Pakistan were observed, with overall HIV prevalence increasing from 16.2% in 2006 to 31.0% in 2011; an increase in HIV prevalence was also seen in all geographic areas except one. There was an increase in risk behaviours between 2006 and 2011, anecdotally related to a reduction in the availability of services for IDU. In 2011, larger proportions of IDU reported injecting several times a day and using professional injectors, and fewer reported always using clean syringes. An increase in the proportion living on the street was also observed and this was associated with HIV infection. Cities differ in terms of HIV prevalence, risk profiles, and healthcare seeking behaviours. CONCLUSIONS: There is a high prevalence of HIV among injection drug users in Pakistan and considerable potential for further transmission through risk behaviours. HIV prevention programs may be improved through geographic targeting of services within a city and for involving groups that interact with IDU (such as pharmacy staff and professional injectors) in harm reduction initiatives.

Patterns and trends in Pakistan's heterogeneous HIV epidemic.

BACKGROUND: Considerable HIV transmission occurs among injection drug users (IDUs) in Pakistan and recently the HIV prevalence has been increasing among male (MSW), hijra (transgender; HSW) and female (FSW) sex workers. We describe past and estimate future patterns of HIV emergence among these populations in several cities in Pakistan. METHODS: The density of these key populations per 1000 adult men was calculated using 2011 mapping data from Karachi, Lahore, Faisalabad, Larkana, Peshawar and Quetta, and surveillance data were used to assess bridging between these key populations. We used the UNAIDS Estimation and Projection Package model to estimate and project HIV epidemics among these key populations in Karachi, Lahore, Faisalabad and Larkana. RESULTS: The density and bridging of key populations varied across cities. Lahore had the largest FSW population (11.5/1000 adult men) and the smallest IDU population (1.7/1000 adult men). Quetta had the most sexual and drug injection bridging between sex workers and IDUs (6.7%, 7.0% and 3.8% of FSW, MSW and HSW, respectively, reported injecting drugs). Model evidence suggests that by 2015 HIV prevalence is likely to reach 17-22% among MSWs/HSWs in Karachi, 44-49% among IDUs in Lahore and 46-66% among IDUs in Karachi. Projection suggests the prevalence may reach as high as 65-75% among IDUs in Faisalabad by 2025. HIV prevalence is also estimated to increase among FSWs, particularly in Karachi and Larkana. CONCLUSIONS: There is a need to closely monitor regional and subpopulation epidemic patterns and implement prevention programmes customised to local epidemics.

Research fatigue among injecting drug users in Karachi, Pakistan.

BACKGROUND: Karachi is the largest metropolis of Pakistan and its economic hub attracting domestic migrants for economic opportunities. It is also the epicenter of HIV epidemic in the country. Since 2004, one pilot study and four behavioral and biological surveillance rounds have been conducted in Karachi. In addition many student research projects have also focused on key risk groups including injection drug users (IDUs). As a result of this extra ordinary exposure of same kind of questions, IDUs know how to respond to high value questions related to sharing of needles or unsafe sexual practices. The purpose of the study was to explore the element of research fatigue among IDUs in Karachi, Pakistan. METHODS: The study was conducted on 32 spots in Karachi, selected on the basis of estimate of IDUs at each spot. A trained field worker (recovered IDU) visited each spot; observed sharing behavior of IDUs and asked questions related to practices in January 2009. Verbal consent was obtained from each respondent before asking questions. RESULTS: On average 14 IDUs were present at each spot and out of 32 selected spots, 81% were active while more than two groups were present at 69% spots. In each group three to four IDUs were present and everyone in the group was sharing. One dose of injecting narcotics was observed. Sharing of syringes, needles and distilled water was observed at 63% spots while professional injector/street doctor was present at 60% spots. CONCLUSION: There is a need to check internal consistency in surveillance research. It is highly likely that IDUs and other risk groups know how to respond to key questions but their responses do not match with the practices.

Determinants of HIV sero-conversion among male injection drug users enrolled in a needle exchange programme at Karachi, Pakistan.

OBJECTIVE: To assess the determinants of HIV sero-conversion among male injection drug users enrolled in needle exchange programme at Karachi. METHODS: An unmatched retrospective case control study was conducted among male injection drug users receiving needle exchange services in Karachi. The cases and controls were identified from one drop in center providing needle exchange services. The data for the study participants was collected retrospectively from the programme. Descriptive statistics, univariat analysis, and multivariate regression analysis for determinants of HIV sero-conversion and Hosmer and Lameshow goodness of fit test for model adequacy were performed. RESULTS: Mean age of the study participants was 34.17 +/- 10.74 years. Average monthly income of the participants was US$ 125.15 +/- 76.32. In unconditional multivariate regression analysis being unmarried (AOR: 3.0 95% CI 1.14-7.9, p=0.02), not living with family (AOR: 2.8 95% CI 1.18-6.79 p = 0.02), family history of addiction (AOR: 2.5, 95% CI 1.01-6.49, p = 0.04), injecting drugs in groups (AOR: 2.8, 95% CI 1.12 7.02 p=0.02), not obtaining syringes from the programme (AOR: 26.45, 95% CI 2.47-282.8 p = 0.007), and history of blood transfusion (AOR: 52.9, 95% CI 1.32-2118.416 p = 0.03) were significantly associated with HIV positive sero-status. Model adequacy was assessed by Hosmer and Lameshow goodness of (J: 4.95, p = 0.7) indicating that the model was accurate. CONCLUSION: Social and drug related risky behaviours are important determinants of HIV among male IDUs in Karachi. The situation calls for programmematic initiatives for addressing the risky behaviours among IDUs for effective control of epidemic in the country.

Assessment of Acceptability of Pre-exposure Prophylaxis for HIV Prevention Among Men Who Sex with Men and Transgender Community in Pakistan.

OBJECTIVE: To assess the level of acceptability of oral pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and transwomen (TW) in Pakistan. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Online study portal from September to November 2021. METHODOLOGY: The study participants were recruited through snowball sampling. Consenting individuals who were >13 years and were identified as MSM or TW were included in the study. Data were analysed using SPSS version 25. Frequencies, percentages and correlation coefficients were computed. RESULTS: A total of 347 participants were recruited. The mean age of all participants was 29.8 ± 6.7 years. Fifty-eight (19.7%) of the participants had chemsex with amphetamine-type stimulants (ATS) at least once in preceding six months of the study, and 58 (19.7%) had a sexually transmitted infection (STI) in preceding six months whereas 10 (3.4%) participants had used drugs via injection. Two hundred and thirty-eight (72%) of the participants were aware of PrEP, 30 (11.7%) had used PrEP in the past, and 3.88% were currently using PrEP. The willingness to use PrEP, free of cost, was shown by 300 participants (86.45%) and by 180 (54.5%), if available at a low cost. CONCLUSION: There was a high prevalence of risk factors posing them at considerable risk of human immunodeficiency virus (HIV). The majority was aware of PrEP for HIV prevention. The willingness to use PrEP was high when PrEP was offered free of cost but dropped down when participants were asked to pay for PrEP. Based on this finding, PrEP should be available free of cost at the community preferred outlets. KEY WORDS: Gay, Men who have sex with men, HIV, Pre-exposure prophylaxis Pakistan, Transwomen, Chemsex, People living with HIV.

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.

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.

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.

Visibility and Analytics Network (VAN) approach to improve immunization supply chain and management performance system in Pakistan.

BACKGROUND: Pakistan has been experiencing several immunization related challenges. The supply chain management information system (MIS) is considered an important component of immunization services as it can improve visibility in key areas such as vaccine shortages or wastage. This study assessed the effectiveness of the Visibility and Analytics Network (VAN) approach in improving vaccine supply and availability of stocks by comparing the situation in intervention and non-intervention districts in Sindh province of Pakistan. METHODS: We utilized a quantitative and qualitative approach to collect data to assess the VAN approach in two districts of Sindh province in Pakistan. The data were collected between August and October 2017. VAN is a systematic monitoring system which measures the performance of vaccine supply chain management based on a set of indicators. We assessed storage facilities of the Expanded Programme on Immunization (EPI) in Sindh and interviewed personnel involved using a pre-tested data collection tool. We also conducted in depth interviews with senior management to assess performance of VAN, adoption mechanism and needs to scale up the VAN approach. RESULTS: We assessed 52 EPI facilities of Sindh province government. In the intervention district 83.3% managers were using MIS data for decision making related to vaccine supplies whereas in the non- intervention district no MIS based data were available. Ninety percent of stores were maintaining a stock registry and 100% supplies matched with requisitions in the intervention district compared to 40% and 35% in the non-intervention district for the same variables. Vaccine wastage was high in the non- intervention district (BCG 46.7% vs 33.9; OPV 13.5% vs 9.5%; pneumococcal 11.4% vs 7.4%). In-depth interview findings suggested that the VAN approach provided data guided monitoring in Pakistan for the first time. The approach also enabled district managers to make timely decisions. CONCLUSION: The VAN approach improves vaccine supply chain management. It should be scaled up and implemented at national or sub national especially in countries struggling with vaccine supply chain management.

Examining unsafe injection practices associated with auto-disable (AD) syringes: a systematic review.

Auto-disable (AD) syringes are specifically designed to prevent syringe reuse. However, the notion that specific AD syringe designs may be unsafe due to reuse concerns related to the syringe's activation point has surfaced. We conducted a systematic review for evidence on the association between AD syringe design and syringe reuse, adverse events following immunization (AEFI), or blood borne virus (BBV) transmission. We found no evidence of an association between AD syringe design and unsafe injection practices including syringe reuse, AEFIs, or BBVs. Authors of three records speculated about the possibility of AD syringe reuse through intentionally defeating the disabling mechanism, and one hinted at the possibility of reuse of larger-than-required syringes, but none reported any actual reuse instance. In contrast to AD syringes, standard disposable syringes continue to be reused; therefore, the global health community should expand the use of AD syringes in both immunization and therapeutic context as an essential strategy for curbing BBV transmission.

Research on health priorities: a regional agenda and its implementation in Jordan and Pakistan.

The Eastern Mediterranean Region (EMR) is facing extraordinary social and health challenges, aggravated by epidemiologic variations, high morbidity and mortality burden (communicable, noncommunicable, injuries), consequences of emergencies (including current COVID-19 pandemic), conflicts and massive migrant population movements. Research for health is essential for generating necessary evidence, which contributes to sustainable development, economic growth and sound health policy-making. Moreover, research for health that addresses national public health priorities is essential for developing required evidence for explanations that contribute towards health improvement and can assist in best utilization of available resources towards issues that maximize the research impact on population health.