Unprecedented rise in human immunodeficiency virus cases in Pakistan: A public health emergency

Abstract

Human immunodeficiency virus continues to pose a severe global and national public health threat. In Pakistan, human immunodeficiency virus incidence has risen alarmingly, with over 9700 new cases reported in the first nine months of 2024 alone. Transmission is fueled by unsafe sex, needle-sharing, and systemic healthcare lapses, including unscreened transfusions and reused instruments. Sociocultural stigma, limited awareness, and poor treatment adherence especially in rural and underserved areas compound the crisis. Men, transgender individuals, and children represent increasingly affected groups. The role of international bodies such as World Health Organization, United Nations Development Programme, and United Nations Women has been critical in expanding community-based care and education programs. Effective biomedical tools like pre-exposure prophylaxis and post-exposure prophylaxis offer preventive promise but remain underutilized. Pakistan urgently needs an integrated, multispectral response i.e., enhancing surveillance, ensuring antiretroviral therapy access, improving healthcare worker training, and promoting harm reduction and eliminating certain stigmas to control the epidemic and prevent further escalation.

Key Words: Human immunodeficiency virus; Epidemiology; Pakistan; Public health; Surveillance

Core Tip: Pakistan is witnessing a sharp rise in human immunodeficiency virus cases, with over 9700 new infections in the first nine months of 2024. Punjab and Sindh are the most affected regions, and males constitute the majority of new cases. This surge underscores the urgent need for strengthened surveillance, awareness, and treatment access.

TO THE EDITOR

The human immunodeficiency virus (HIV) continues to be a pressing public health issue worldwide, affecting over seventy-five million individuals since its discovery, with an estimated thirty-seven million people currently living with the virus. HIV leads to acquired immunodeficiency syndrome (AIDS) if left untreated. There are two major strains of HIV: HIV-1, which is more prevalent and pathogenic globally, and HIV-2, which is mostly confined to West Africa and associated with a slower disease progression[1]. The principal routes of HIV transmission include unprotected sexual intercourse (heterosexual and homosexual) particularly when one partner is infected, intravenous drug use through contaminated needles, transfusions with unscreened blood products, and perinatal transmission from mother to child during childbirth or breastfeeding. High-risk groups include men who have sex with men, injecting drug users, healthcare workers exposed to contaminated instruments, and neonates born to HIV-positive mothers[1]. As per the literature, nearly all AIDS patients harbor detectable levels of HIV RNA in their bloodstreams if left untreated[2].

Pakistan, a country that has been dealing with a concentrated HIV epidemic for over two decades, has seen a significant increase in HIV cases in recent years. Between 2002 and 2019, multiple regional outbreaks occurred, predominantly in Punjab and Sindh provinces, raising concern about systemic healthcare weaknesses and public awareness deficits[3]. In 2024, Pakistan has witnessed a substantial escalation in HIV incidence. According to recent national data, over 9700 new HIV cases were reported in just the first nine months of the year, averaging approximately 1079 new cases each month. These numbers are expected to surpass 12950 by the end of the year, exceeding the 12731 cases documented in 2023[4]. This rise is not evenly distributed across the provinces. Punjab leads with 5691 cases reported between January and September 2024, indicating a strong concentration of the epidemic in the most populous region[5,6]. In Sindh, 2531 new HIV infections were reported by October 2024, with Karachi alone accounting for 635 cases.

These figures highlight the continued public health crisis in urban and semi-urban centers[7]. In Khyber Pakhtunkhwa, 1147 new cases were identified, bringing the province’s total number of registered HIV patients to 8356. The primary hotspots within Khyber Pakhtunkhwa include Peshawar, Bannu, and Mardan, although recent data also implicate Dera Ismail Khan as a growing concern[8]. In previous years, areas like Larkana in Sindh reported significant pediatric HIV outbreaks due to the reuse of contaminated medical instruments and unsafe transfusion practices, reinforcing concerns about systemic healthcare lapses. For example, in 2019 alone, 876 individuals, including 719 children, tested HIV-positive in Larkana district, many of whom did not receive timely treatment[3,9].

An alarming aspect of the HIV crisis in Pakistan is the changing demographic profile of those infected. According to a recent 2024 report, approximately 69.4% of new HIV cases were among men, 20.5% among women, 4.1% among transgender individuals, and 6% among children, suggesting multiple transmission sources and inadequate maternal screening protocols and contrary to the global trends of more cases reported in men and putting emphasis on no-gender discrimination by the disease[6,8]. In Khyber Pakhtunkhwa, a detailed breakdown reveals that sexual transmission remains the most common mode, accounting for over 5126 cases, followed by unsafe injection practices (1102 cases) and contaminated blood transfusions (818 cases). These statistics highlight the gaps in both public education and regulatory enforcement within the medical system[8]. In 2024, Balochistan reported 462 new HIV cases, increasing the total number of registered patients to 2823. However, health officials estimate the actual number of cases to be between 7000 and 9000 due to underreporting and limited testing[9]. Between January and October 2022, Islamabad recorded 519 new HIV cases, with a significant proportion among young men aged 18 to 25 years[10].

HIV care in Pakistan also faces a number of structural and behavioral barriers, particularly related to adherence to antiretroviral therapy. A cross-sectional study conducted in Lahore found that 45.5% of HIV-positive individuals delayed treatment because they perceived themselves as healthy and believed treatment was unnecessary[5,10]. Additionally, 42.6% cited lack of time as a reason for non-adherence. Fear of social stigma and discrimination discouraged 35.6% from seeking timely medical care, and 32.4% of participants had no formal education, contributing to low health literacy regarding HIV and its treatment. Furthermore, patients in rural regions continue to experience difficulty in accessing HIV care due to distance and the scarcity of treatment centers[10,11]. These findings reveal a multi-dimensional public health challenge. On one hand, the increasing number of HIV cases underscores a failing in containment, prevention, and education strategies. On the other, the reasons for delayed treatment-ranging from stigma to logistical issues-highlight the need for community-based intervention, policy reform, and healthcare infrastructure improvements. While international guidelines recommend regular awareness campaigns, harm-reduction strategies for drug users, and mandatory screening of blood products, Pakistan’s implementation remains fragmented. Inadequate training among healthcare providers, particularly in rural areas, further exacerbates the situation. Pakistan’s healthcare response must now evolve to meet this public health emergency.

A multispectral approach involving initiatives i.e., needle exchange programs in Iran (or community education in India) by federal and provincial governments, non-governmental organizations, public health educators, and media outlets is imperative. The role of international bodies has been crucial i.e., World Health Organization (WHO) and United Nations Development Programme serve as the principal recipients of the Global Fund HIV grant in Pakistan. They have expanded community-based HIV prevention services from 16 to 53 sites across 19 cities, reaching over 1.3 million individuals from key populations. United Nations Women has partnered with Pakistan’s National AIDS Control Programme to address the specific needs of women affected by HIV[11]. HIV prevention strategies i.e., pre-exposure prophylaxis and post-exposure prophylaxis are crucial in prevention of HIV transmission. Pre-exposure prophylaxis involves daily or event-driven use of antiretrovirals (e.g., tenofovir disoproxil fumarate/emtricitabine) by HIV-negative individuals at high risk to prevent infection.

Post-exposure prophylaxis is a 28-day antiretroviral regimen started within 72 hours of potential HIV exposure to prevent seroconversion. Both are highly effective biomedical strategies recommended by WHO and Center for Disease Control and Prevention for HIV prevention. This includes strengthening disease surveillance as enhancing point-of-care HIV testing sites, as recommended by the WHO based on Thai studies, can significantly improve early HIV detection and treatment[12]. This is because point-of-care testing allows for immediate results, leading to quicker linkage to care and treatment. Increasing the availability and accessibility of antiretroviral therapy, ensuring the sterility of medical equipment, mandating HIV screening in pregnancy, and de-stigmatizing HIV/AIDS through culturally sensitive community outreach.