HIV: A PUBLIC HEALTH ISSUE

13 min readAug 1, 2022

HIV: A PUBLIC HEALTH ISSUE

Abstract

HIV is one of the major health issues around the world. It is a virus that weakens the immune system and transfers through bodily fluids. The most dangerous form of HIV is AIDs which decreases a human being’s lifespan to less than a year if left untreated. Three years ago, there was a major HIV outbreak in the Larkana district of Sindh, Pakistan. The government could barely deal with it through mass screenings and international intervention. Nevertheless, there were still many long-term problems that were left unresolved. We will form a plan by using the steps taken by the government to deal with that outbreak and use our leadership and commissioning skills to address its long-term problems and sustainability.

Table of content

Section 1…………………………………………………………………………………………………………………….3

Public health issue………………………………………………………………………………………………………3

Origin………………………………………………………………………………………………………………………….3

Stages………………………………………………………………………………………………………………………….3

Methods of transmission…………………………………………………………………………………………….3

Case study……………………………………………………………………………………………………………………4

Section 2………………………………………………………………………………………………………………………4

Reported cause……………………………………………………………………………………………………………4

Steps taken by the government…………………………………………………………………………………..5

Outcomes…………………………………………………………………………………………………………………..5

Section 3……………………………………………………………………………………………………………………..6

Plain for intervention……………………………………………………………………………………………………6

Solutions………………………………………………………………………………………………………………………6

Conclusion……………………………………………………………………………………………………………………9

References………………………………………………………………………………………………………………….9

Section 1

Public Health Issue

HIV (human immunodeficiency virus) is a type of disease that weakens the immune system by damaging the blood cells and reducing your ability to fight against infections and other diseases. The virus is transmitted through bodily fluids like semen, vaginal fluids, and blood, but it cannot transmit through saliva or urine and cannot survive outside the body for much time.

Origin

HIV has become a leading public health issue since it emerged in the early 1970s. It has claimed over 36.3 million lives so far (World Health Organization). The virus’s origin can be traced back to the early 1800s. HIV allegedly came from Chimpanzees in Africa; the basis of this claim is its similarity with a similar virus in chimpanzees called Simian immunodeficiency disorder. Back in the day, humans hunted these Chimpanzees for meat so that they might have come in contact with their infected blood. In the following decade, as the world globalized, the virus spread more rapidly until the first outburst was recorded in 1942 in America.

Stages

HIV has no cure yet, but some medications can suppress it enough so a patient can live almost an everyday life. The biggest issue of this virus is that it has no specific symptoms. The virus progress in three stages:

Stage 1: when a human is exposed to the virus, they may not feel symptoms for the first few days. In a typical case, an exposed person develops flu-like symptoms after 2 to 4 weeks of exposure.

Stage 2: in this stage, the virus enters the blood and starts weakening the immune system. This stage can last from months to even decades. Most people get tested at this stage, and if left untreated, they reach the most dangerous stage, which is AIDs.

Stage 3: AIDs (Acquired Immunodeficiency Syndrome) is the most dangerous stage of HIV. People with AIDs carry the highest load of HIV and are most likely to transmit it to others. A patient with AIDs is very susceptible to other diseases and viral infections, which shorten their life expectancy to less than three years. If the patient is not receiving any medication, it drastically falls to less than a year.

Methods of Transmission

HIV transmits from one person to another. Its transmission from parents to children is unlikely, but it is highly possible if both parents have HIV. The two most significant methods of transmission for HIV are sexual intercourse and infected needles due to sharing of injections.

1. Sexual Intercourse

The leading cause of HIV is having sexual intercourse with a person who may be carrying the virus. As discussed earlier, the virus transmits through bodily so having intercourse with an HIV carrier has a 2% risk of infection. In case of anal intercourse the risk jumps to an alarming 20% rate of infection. This percentage may not sound a lot, but it is still risky. Homosexuality is also a major reason for HIV wide spread in the recent years. According to a survey conducted by the World Health organization male to male sexual intercourse has a 35% risk infection if one partner is an HIV carrier. The best way to avoid HIV transmission during intercourse is through male and female protection.

2. Infected Needles

There are 37.7 million people currently living with HIV (World Health Organization), and many are minors who have never been involved in any sexual activity. Most children who have HIV get it from using infected needles, especially during vaccination. When a needle enters the blood of an HIV carrier, it becomes infected, and the use of these injections significantly increases the chance of transmission if they are not adequately sterilized. The easy way to avoid this transmission is not to use the same needle twice or use it in case of emergency after proper sterilization.

Case study

The first case of HIV in Pakistan was reported in 1987. In the following decades the number of cases reported by the National services reported negligible number of cases and Pakistan was considered free from HIV. In early April 2019, medical officials started noticing symptoms in incoming children. After further testing, he reported that many children have tested positive for HIV in a short period. The government took notice of that, started a media campaign warning people about the outbursts, and started citywide testing. They took more than 26,000 samples, out of which around 800 came positive, most of which were children. The government started investigating to get to the root of the problem.

Section 2

Reported Cause

According to the Sindh Aids Control Program (SACP) report, the most significant cause of this outbreak was using infected needles for medical purposes. The district of Larkana is a backward area, and there is little awareness about proper medical procedures, especially in public hospitals. Many unlicensed and ineligible hospitals and clinics used to treat patients with the same injection over and over without proper sterilization, which led to many children being infected by HIV.

Other Determinants

HIV and other sexually transmitted diseases are considered taboo which leads to hindering the awareness process. As a result, most people do not even know they can be infected by other means, including sharing injections.

Steps to tackle the problem

The Sindh government took three significant steps to tackle this outburst

1. Mass Testing

The first significant step government took after the outburst was to start screening of masses. They pinpointed the areas with the highest number of unlicensed clinics and took maximum samples. They form many testing hubs to take blood samples and establish a facility at Taluka headquarters hospital in Ratodero. The SACP took over 26,000 samples with a 3% positive turnover (primarily children).

2. Shutting Down of Unlicensed Clinics

The Sindh health ministry also tightens its grip on medical malpractices to prevent any form of informal medication.

As a result of their effort, over nine hundred unlicensed small hospitals, clinics, and blood banks were shut down in a few months.

3. The intervention of International Bodies

After the outburst, United Nations intervened to help Pakistan through the crisis. UNICEF UNAIDS and UNFPA worked closely with the Sindh health department to implement the “Sindh HIV Outbreak Response Plan May 2019-April 2020”. The main objective of this plan was to identify the causes of this outbreak and the long-term prevention and treatment of this virus.

Outcomes

These steps taken by the government and UN intervention had great success in dealing with this outburst, but there is still a lot left to deal with.

· Success

The efforts made by the government dramatically improved the health system of Larkana. Most of the unlicensed clinics involved in medical malpractice were shut down. The remaining medical facilities started following the correct treatment protocol, which elevated the population’s health standard in that area. They were also able to provide AVR treatment to 356 infected patients timely.

· Problems

The root problem remains. Talking about HIV is still considered taboo because it is a sexually transmitted disease that hinders its awareness. The government failed to start a campaign that normalized HIV discussions and awareness. Another big problem is funding. HIV medication and treatment are not cheap. Even after the outburst, the program could only provide treatment to half of the patients. Funding is a significant problem, especially in developing countries, it keeps many men, women, and children from getting the proper treatment, and as a result, they end up having AIDs.

Section 3

Main

Plan For intervention

A plan to tackle HIV is essential in Pakistan right now. According to the world health organization, Pakistan has the second highest HIV rate in the Asia Pacific region, with over 1000 children living with HIV in Pakistan. Unlike other countries, the HIV outbreak in Pakistan was not followed by many studies to devise a plan to tackle the same issue in the future. The best way to tackle HIV is to identify the core and carrier groups and devise a nationwide plan to tackle the HIV epidemic. For that purpose, first, we have to differentiate between the core and carrier groups.

· Core group

This group is identified as the people to whom the virus was first introduced. The leading cause of HIV in Pakistan is injection sharing, which is most common in injecting drug users (IDU). According to a survey conducted in 2003, there were around one hundred and forty thousand IDUs in Pakistan, and most of them take drugs in the form of a group and share the same syringe, which leads to HIV prevailing at about 20% annually.

· Carrier group

Almost 46% of these IDUs have sexual intercourse with their partner or a commercial female sex worker (FSW). These female sex workers have about 7 to 10 clients a week (Punjab AIDs control program 2008). Even with a 2% transmission rate, the number of HIV-infected people in the country could be very alarming.

Solutions

The government has taken steps towards the right direction by starting an “Enhanced HIV/AIDs controlling program” and has spent 70 million dollars of its own money to finance this program. The program may be an excellent starting point. It is far from tackling the whole issue. The problem is that this program is geographically limited, while IDUs in Pakistan is widespread throughout the nation. The government needs to reach every city and district. The only solution is to open a facility in every district that only works to address the issue of HIV and its prevention and awareness. This proposal may sound like a financially unsustainable idea, but it is not, and the reasons for that are mentioned below.

1. Commissioning

Devising a plan of this level requires an expert level of knowledge and sensitive planning to ensure that the program is implemented correctly. Leadership and commissioning are one of the main areas where Pakistan is severely lacking. This gap in the commissioning departments leads to the failure of most of its major projects, and the funds disappear in terms of corruption.

If I become the commissioner of this program, I would open a specific facility for HIV/AIDs related issues in every government hospital throughout Pakistan. The problem is that people consider it taboo to visit HIV clinics themselves as it indicates they have a sexually transmitted disease, so the taboo will no longer exist by opening a facility in government hospitals.

In Pakistan, most government hospitals are pretty big in terms of area and infrastructure, but a big chunk of that area is non-functional; this course of action not only solves the problem of area and infrastructure but will also put that unutilized part of the hospital to good use.

2. Funding

The biggest problem that arises in a project of this magnitude is funding. Pakistan is a developing country, and its health system is already receiving insufficient funds. So how can they support a country-wide project? According to the plan I devised, there will be three primary funding sources.

· International partners

Pakistan has worked with UN organizations in the past on many different occasions. Now is when international bodies like WHO and UNICEF need to intervene and provide the nation with sufficient funds so that Pakistan can implement this program. Other international bodies they can turn to are the World Bank and International Monetary Funds, which have provided significant funds for outbreaks like these.

· Government funding

No program of this magnitude can move forward without funding in some way, shape, or form. If the government forms collaborations with educational institutes, as discussed below, they will have to spend money on student allowance and scholarships, but even that Is not nough. The health budget will have to increase, even if not by much, and the marginal cost will be specific for the HIV department.

· Donations

Perhaps this plan’s most significant and challenging funding source would be donations. To get people to donate for HIV-related issues, the government must ensure that people are aware of it. In a society where the masses do not want to be associated with disease, the first course of action is to break that taboo through awareness campaigns and comprehensive surveillance. Electron media will acknowledge the HIV charitable work. This free positive PR will attract many big corporations and even the masses to donate to this cause. So if the plan is implemented correctly, donations have a high potential to be the primary source of income for this project.

3. Collaborations

As mentioned, Pakistan is already working with USAID, UNICEF, and UNFPA on the “Sindh HIV Outbreak Response Plan May 2019-April 2020”. These UN organizations should be aware of the HIV-related issues in Pakistan through data backed up by proper surveys and case studies. They should be encouraged to send their delegations to visit Pakistan.

Most of Pakistan’s population is under 21, and most are students. Another way of forming collaborations is by starting volunteer programs for students of schools and colleges to participate in surveillance and awareness campaigns in their local areas. Universities are very diverse because students from all over the country come for higher education. Suppose the government offers students scholarships for their services as volunteers as part of HIV programs. In that case, it can significantly impact society and break the taboo, which is the main reason HIV widespread still goes undetected in many areas until there is an outbreak like the Larkana district case.

Finally, just like starting the “Enhanced HIV/AIDs controlling program,” the government can partner up with NGOs and urge them for mass level screening and surveillance and make sure that all the IDUs which form the origin group enter the rehabilitation program, which will address the problem right at its origin.

4. Staffing Issue

One of the most significant issues will be hiring staff for this facility. As mentioned earlier, the facility will be part of the government hospitals of that district. One solution is that the hospital staff will tend to this facility as well as they are already there, and it is part of their job to tend to all kinds of patients. However, that might not be feasible because the staff is already burdened in most government hospitals.

A good fact about HIV screening is that doctor is not needed to take the blood sample. As mentioned before, collaboration is one of this program’s main components. So the students who become part of this can be trained to collect blood samples from patients. This volunteer work can be a good learning experience for early medical students who have not started their residency yet.

Even with trained professionals, a doctor’s presence is still necessary for a medical facility. For that, the hospital can hire an extra doctor, or they can schedule their doctors in such a way that one of them is always available for HIV.

5. Allocation of funds

Corruption is one of the significant issues for a developing country like Pakistan. Even if the plan is precisely followed and the government can muster up resources, there is a high chance that the funds will not reach the general public. For this purpose, a new system needs to be introduced in which the funds are under the direct eye of the commissioning body.

Our plan addresses this issue by transferring the funds in 2 different ways:

· Allocation of funds to hospitals

The funds required to run the HIV facilities in hospitals for testing and treatment purposes will be transferred directly to the hospital management, under the direct eye of the assistant commissioner of that district. Having a supervising body at all times will massively reduce the risk of corruption.

· Allocation to NGOs

Funds are not just required for testing and treatment. As mentioned before, the general public should be made aware of HIV, its detectability, and treatment to get donations. NGOs would work perfectly here. The government will provide direct funds to NGOs for their awareness campaigns and surveillance of the masses. To keep the public’s funds from falling into the wrong hand, the NGOs need to be registered with the government. Only the NGOs deemed eligible to receive funds will get them from the government.

6. Sustainability

It would be tough to sustain a project of this magnitude in the long term. However, long-term sustainability is the need of the hour. Even in the Larkana district incident, only half of the infected patients were able to receive treatments due to insufficient supplies and poor management skills.

The world health organization claims there could be up to 165,000 HIV patients in Pakistan and most of them are dangerously close to acquiring AIDs due to a lack of screening and treatment. Although this number is highly inflated, many local institutes claim it to be roughly half of that number which is still very alarming.

The only way to address the HIV issue is if we form permanent departments and facilities in every major government hospital in a district. Unlike the HIV facilities formed during the Larkana crisis, these facilities will be permanent and continue to function as a part of the hospital itself.

Conclusion

The Larkana outbreak showed that Pakistan desperately needs an HIV-centered project to prevent and deal with future outbreaks. The system provided in this essay addresses all the issues of HIV and its policy implementation, and even in the best-case scenario that the project goes perfectly, it is not enough. The biggest issue is ignorance. People should be made aware of HIV and how one can avoid being infected by it. This information should be taught in schools. Other prevention methods like protection and contraceptives should be more normalized. Only then this horrific public health issue can be resolved appropriately.

Reference Links

https://www.unaids.org/en/resources/presscentre/featurestories/2019/june/20190611_larnaka_outbreak

https://ieeexplore.ieee.org/abstract/document/1409997

https://scholar.google.com.pk/scholar?q=hiv+epidemic+case+study&hl=en&as_sdt=0&as_vis=1&oi=scholart

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007288/

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0022449#pone.0022449-Bokhari1

https://journals.lww.com/aidsonline/fulltext/1997/07000/hiv_aids_and_its_risk_factors_in_pakistan.2.aspx

https://www.sciencedirect.com/science/article/abs/pii/S2352301821000497

https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=HIV+oubreak+in+larkana+case+study&btnG=

http://www.emro.who.int/pak/pakistan-news/pakistan-hiv-outbreak-in-sindh-province.html

https://sti.bmj.com/content/89/Suppl_2/ii11.short

https://www.cdc.gov/hiv/basics/whatishiv.html