Feature Story

Pakistan’s capacity to effectively respond to the HIV epidemic could be hindered due to the lack of resources to implement its revised National Strategic Framework. The framework, endorsed by partners involved in the response, provides evidence-based strategic direction to urgently address the increasing levels of HIV infection amongst injecting drug users (IDUs) and other populations through sexual transmission and avoid a spillover to the general population.

Despite having an HIV prevalence of less than 0.1% among its general population, Pakistan’s HIV epidemic has transitioned from low to a concentrated one as the overall prevalence among IDUs has steadily increased from 10.8% in 2005 to nearly 21% in 2008.

In part, the region’s comparatively heavy burden of injecting drug use stems from the presence of long-standing trafficking routes for illicit opium. Opiates are the drug of choice for 65% of Asia’s drug rehabilitation patients, although drug use patterns vary greatly within the region. There are an estimated 91, 000 injecting drug users in Pakistan of which nearly one in four in large urban settings are infected with HIV.

An increase in resources available would increase the provision of harm reduction services that are producing positive results mitigating the spread of HIV amongst IDUs. Credit: P.Virot

Syringe Exchange Programs and Drug Harm Reduction including detoxification programs for IDUs are a priority in light of the epidemic trends among IDUs. Substantial scale-up of harm reduction and HIV prevention services started around 2002-2004 and the country is now set to pilot drug substitution among drug users. Harm reduction services are being implemented by partner NGOs which can play a pivotal role in reaching out and expanding the provision of such services.

Biological and behavioral surveillance studies have shown an increase in knowledge regarding HIV, increase in condom use and decreased sharing of syringes/needles among IDUs exposed to risk reduction program activities. However, coverage of these programs is still low. An increase in resources available would expand the provision of risk and harm reduction services that are producing positive results mitigating the spread of HIV among populations at higher risk.

Knowing your epidemic

Following the trend seen in other countries in Asia, also known as the Asian Epidemic Model, the epidemic in Pakistan is characterized by the rapid HIV transmission and high prevalence among IDUs in the initial stages and potential spill-over into other key populations at higher risk such as sex workers and men who have sex with men (MSM). Subsequently, through bridging populations such as partners and clients of sex workers, the epidemic could find its way into the general population. The connections and overlap between drug use and sex work coupled with high prevalence of unsafe sexual practices and low self risk awareness indicate that there is potential for rapid spread of HIV infection among key populations.

The overall HIV prevalence among injecting drug users in Pakistan has steadily increased from 10.8% in 2005 to nearly 21% in 2008. Credit: P.Virot

One of the implementation successes in the country is the 2nd generation surveillance for tracking trends in the epidemic. A country specific methodology has been developed, with mapping of risk groups in the first phase and collection of behavioral and biological data after mapping has been completed. This has provided up to date information on size of risk groups as well as on HIV prevalence among them.

Epidemiological evidence gathered over the last years has therefore confirmed Pakistan’s ‘concentrated’ epidemic. It has also underlined the low levels of adoption of HIV prevention measures in the general population and among youths.

Adapting the response

In line with the epidemic trend, supported by results from recent surveillance data, the Government of Pakistan has recently reviewed its National Strategic Framework (NSF-II). The new five year initiative (2008 – 2012) builds upon the initiatives outlined in the first national framework and renews focus towards rapidly scaling up prevention and HIV service delivery programs for most at risk populations.

The country has drafted its national AIDS policy and legislative framework, through the ‘HIV & AIDS Prevention and Treatment Act’, in order to support the government in providing services to populations at risk of acquiring HIV infection due to their occupation and/or practices. The basic provisions of the policy are intended to guarantee access to care, support and equitable access to treatment for people living with HIV. It is also intended to reduce stigma and discrimination against people living with HIV as well as to improve access to HIV specific information and prevention services.

“Pakistan has made substantial progress over recent years, including in addressing sensitive social issues and increasingly involving people living with HIV in the forefront of the AIDS response” says Oussama Tawil, UNAIDS Country Coordinator, “however, it is now critical that a collective effort be made to sustain the momentum in these life-saving measures”.

Lack of resources

AIDS could have a severe impact in certain communities over the coming decade. Financial and human resources are urgently needed to scale-up the provision of HIV prevention, treatment, care and support services. Credit: P.Virot

Despite having a thorough plan of action built upon evidence-based recommendations, the country is facing a shortage in resources that could jeopardize an effective and timely response to the epidemic.

A costing exercise undertaken by the Government estimated that the total fund requirement to implement the NSF II is US$ 293 million over five years. During 2006-2007, AIDS expenditure totaled US$ 29.67 million, with prevention-related activities having been allocated the biggest share (61%).

While resources have been made available to the country by the World Bank, bilateral funding and government resources, these funds are insufficient to cover the current needs and to create a sustainable long-term capacity to address the HIV response in the future.

AIDS could have a severe impact in certain communities over the coming decade. Financial and human resources are urgently needed to scale-up the provision of HIV prevention, treatment, care and support services in order to have a definite impact on the HIV epidemic and to mitigate its social and health consequences.