Pakistan

It was a rainy night when Asghar Satti, the National Coordinator of the Pakistan Association of People Living with HIV (APLHIV), went home after spending a busy day at the office.

That day, he had received a call from a man in Karachi, Pakistan, who is living with HIV. He was worried that he was running low on his supply of antiretroviral therapy, with only nine days of treatment left. That call was one of many such calls that he had received since the beginning of the lockdown put in place after the first case of COVID-19 was identified in Pakistan in late February.

“We need to do something that really benefits the community, we must ensure that HIV treatment adherence is not compromised,” Mr Satti thought.

In order to do just that, the APLHIV set up its Emergency Response Cell (ERC) in March. The ERC is working to ensure that everyone on HIV treatment gets an adequate supply of antiretroviral therapy, often delivered to their door.

Developed by the APLHIV, together with UNAIDS and Pakistan’s National AIDS Control Programme Common Management Unit for AIDS, TB and Malaria, the ERC’s Costed Contingency Plan groups all people living with HIV who are on treatment into three groups: red (people with a supply of antiretroviral therapy for less than two weeks); yellow (people with a supply of antiretroviral therapy for a month); and green (people with a supply of antiretroviral therapy for more than a month). These groups are then used to prioritize who receives packages of antiretroviral therapy, provided by the National AIDS Control Programme, through APLHIV and the Provincial AIDS Control Programme. The National AIDS Control Programme, through its Procurement and Supply Management Unit, provides packages of antiretroviral therapy to APLHIV, which are delivered by APLHIV through courier services to the doorsteps of people living with HIV who are unable to reach treatment centres. 

As well as ensuring HIV treatment, other services provided by APLHIV include education for people living with HIV and key populations on COVID-19—more than 70 000 short messages in the local language on how to prevent COVID-19 were sent during the first four weeks of the lockdown. APLHIV, in close collaboration with the Provincial AIDS Control Programme, is also monitoring the 45 centres nationwide that provide antiretroviral therapy, checking that they have sufficient stocks of treatment and that people living with HIV are being provided with services without stigma and discrimination.

With a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria, APLHIV has provided nutritional support to more than 3200 people living with HIV in need. “You can never imagine what this support means to me, when I don’t have a single penny to feed myself or my siblings. The help we reached is a blessing from God,” one of the recipients said.

APLHIV, which has more than 15 000 people living with HIV from across Pakistan in its network, has also linked around 4000 people living with HIV with one of the social protection programmes launched by the government to support people in need during the COVID-19 pandemic.

“APLHIV will continue operating the Emergency Response Cell until the COVID-19 pandemic ends in the country,” Mr Satti said.

“Working with the community with APLHIV is always fulfilling. The work almost always centres around finding local solutions to effectively respond to the evolving needs of the people, of the community. It is not always easy, but with constant dialogue, innovative ideas are born and then nurtured. This multimonth antiretroviral therapy dispensing and the simple use of different colours to depict level of antiretroviral therapy available, which people can easy understand, is another home-grown innovation we are proud of,” said Maria Elena Filio Borromeo, UNAIDS Country Director for Pakistan and Afghanistan.

Sitting near her broken window, Ashee Malik (not her real name), a transgender woman who lives in Punjab Province, Pakistan, is counting her earnings, realizing that her income has fallen sharply. Her only source of money is dancing, begging and entertaining her clients, but since the lockdown imposed on 20 March to stop COVID-19, she hasn’t been able to leave her home. Her bright clothes are in her wardrobe, as is her makeup kit, laying unused for weeks. “We are concerned about our well-being, as we do not have enough resources to support ourselves and our families,” she said.

Ms Malik’s story is similar to that of most transgender people living in Pakistan, who face stigma, discrimination and social isolation. Access to health services, education and employment is one of the many challenges that transgender people face in the country, despite the passing of the Transgender Persons Protection of Rights Act 2018. And COVID-19 and the associated lockdown are making matters worse. As of 15 April, there were more than 5900 confirmed cases of COVID-19 in Pakistan and 107 deaths. 

Owing to the restrictions on the movement of people, there is a real risk of a disruption to critical services for people living with HIV, which disproportionality affects transgender people in Pakistan.

The Khawaja Sira Society (KSS), which works with transgender people, has stepped in to provide support, working with the most marginalized and promoting knowledge about how to prevent HIV and COVID-19.

“The transgender community is even more vulnerable due to the prejudice and stigma and discrimination against them. We need to develop a COVID-19 prevention model by keeping in mind the dynamics and issues of the community in this pandemic,” said Mahnoor Aka Moon Ali, the Director of Programmes for KSS.

During discussions that KSS had with 150 transgender people, of whom approximately 30% are living with HIV, several issues were repeatedly raised, including the lack of income and the small size of Dheras, community homes for transgender people, in which four or five transgender people live together, making social distancing difficult. Since most of the transgender people contacted are illiterate, public health campaigns on how to prevent infection by the coronavirus are not getting through. Fear of the disease is high, which is impacting on mental health. The Government of Pakistan has announced that food aid will be made available, but transgender people face challenges in accessing the scheme, which is dependent on verification based on the national identification card, something that most transgender people in the country simply don’t have.   

Social media is increasingly being used during the lockdown and together with UNAIDS Pakistan, KSS is disseminating information on hygiene, preventive measures and social distancing on social media and is engaging with the community on COVID-19. KSS, together with provincial government authorities, is also working to ensure that people living with HIV can get multimonth refills of antiretroviral therapy delivered to their home.

“We as transgender people living with HIV feel we are at risk by visiting government-run antiretroviral therapy centres. We need antiretroviral therapy to be delivered to us,” said Guddi Khan, a transgender woman who is living with HIV.

Since an uninterrupted supply of antiretroviral therapy is essential for people living with HIV, the Pakistan Common Management Unit for AIDS, TB and Malaria, in collaboration with UNAIDS and other partners, has established virtual platforms and helplines in order to ensure that coordination is continued. An emergency stock of antiretroviral therapy has been made available for people living with HIV for the next two months and a buffer stock is being made available through the Global Fund to Fight AIDS, Tuberculosis and Malaria in order to avoid interruptions in the event that imports of medicines are disrupted.  

“We are working closely with the Association of People Living with HIV, federal and provincial governments and the UNAIDS family to monitor the situation and quickly help address barriers in accessing life-saving HIV services in these extremely challenging times of the COVID-19 crisis,” said Maria Elena Borromeo, the UNAIDS Country Director for Pakistan and Afghanistan.

A newly refurbished paediatric centre is to open in Ratodero, Pakistan, to serve families affected by the recent HIV outbreak in the district of Larkana. It is expected that the centre will be operational by mid-July.     

Alia (not her real name), the mother of a two-year old girl, lives in the village of Mirpur Bhutto, in Ratodero Taluka in Larkana district.  Alia’s world has been turned upside down since her family was caught up in the HIV outbreak in the area.    

“My daughter was diagnosed with HIV just a few days ago, but she became so weak so quickly. She couldn’t eat anything we gave to her,” says Alia. After Sameera’s (not her real name) diagnosis, she was referred to Sheikh Zayed Children Hospital in Larkana to start antiretroviral therapy.  The hospital is more than 50 kilometres away from the family home.

“I got these dispersible tablets for Sameera and some fever medicine, and since she started her treatment, I have seen some improvements in my daughter’s health. Her fever has gone and before there was diarrhoea from which she also recovered,” explains Sameera’s mother.

Alia’s husband is a farmer and earns less than two dollars a day. “We can hardly support our family of ten members,” she explains.  

Poor road conditions and economic constraints make it difficult for Alia and her daughter to travel from their village to the district capital Larkana, currently the nearest health facility where her daughter can receive the treatment she needs.

Since the HIV outbreak was first reported in Larkana at the end of April, UNAIDS, UNICEF, the World Health Organization, the Sindh AIDS Control Programme and other partners have been calling for a new paediatric treatment centre in Ratodero to bring HIV services closer to the affected communities. As a result of these efforts and in the framework of the “Sindh HIV Outbreak Response Plan, May 2019-Apr 2020,” UNICEF is refurbishing the paediatric HIV treatment centre at Taluka Headquarters hospital in Rotadero, ensuring that treatment will be available in the area where Alia and her daughter live. When the new centre opens, HIV treatment services for Sameera will be less than 10 kilometres away.     

“I know my Sameera will be fine and that she will get married and have children. This is what the doctor told me. For this to happen she must continue her treatment forever.  I will follow the doctor’s instructions because this is what will save my daughter’s life,” says Alia.   

By the end of June, 877 people had been newly diagnosed with HIV in the Larkana district. More than 80% of the new cases are among children aged under 15 years old. A total of 721 people had already been registered in care programmes and 482 people (365 of them children under the age of 15) were on treatment.

“UNAIDS is working closely with the government, civil society organizations, the association of people living with HIV, UN agencies and all other partners to ensure that both the immediate response to the HIV outbreak and longer-term programmatic measures will be implemented and sustained,” said Maria Elena Borromeo, UNAIDS Country Director for Pakistan and Afghanistan.

UNAIDS is continuing its support to Pakistan in responding to the outbreak of HIV in Larkana, during which more than 800 people have been newly diagnosed with the virus. More than 80% of the new cases are among children aged under 15, with most among children aged under 5. By 17 June, 396 people had been referred to treatment.

At a press conference on June 14 the authorities presented the findings of a preliminary investigation into the outbreak. It concluded that poor infection control practices, including a lack of sterilization and the re-use of syringes and intravenous drips, are the most significant factors behind the rise in new infections.

“There is a huge amount of work that needs to be done to improve infection control and support the affected children and their families,” said UNAIDS regional director, Eamonn Murphy, during the press conference held in Karachi, Pakistan. “UNAIDS will continue to facilitate and coordinate within the United Nations system and with other partners to ensure that the required support is provided effectively and efficiently,” added Mr Murphy.

As well as improving infection control procedures, the preliminary investigation found that strengthening community education is critical to raise awareness about HIV prevention and to tackle stigma and discrimination. The conclusions of a rapid assessment on HIV-related knowledge presented at the press conference found that information about HIV is very limited among the affected communities. Many parents and caregivers learnt about HIV only on the day their children were diagnosed or because of media reports about the increase in cases. A lack of accurate information created panic and some families with children diagnosed with HIV have been shunned and isolated.

In response, UNAIDS in partnership with UNICEF, UNFPA, the World Health Organization and the JSI Research and Training Institute have been supporting national partners to develop a community response plan to promote health education and reduce stigma and discrimination. The Sindh AIDS Control Programme, together with UNAIDS and UNICEF, has started to train health workers on paediatric case management and health education sessions are being organized with the involvement of community led organizations and religious leaders. Training sessions for local media on responsible HIV reporting are also being carried out.

UNAIDS has been working closely with the federal and provincial governments to provide on-site technical support to help respond to the crisis and mitigate its impact. Sindh’s Ministry of Health has increased its efforts to prevent unlicensed and informal medical practices from operating and, as a result, 900 health clinics and unlicensed blood banks have been closed.

The preliminary investigation was led by the World Health Organization, in partnership with organizations including the Sindh AIDS Control Programme, Aga Khan University, the Field Epidemiology and Laboratory Training Programme, the Dow Medical University in Karachi, the Microbiology Society of Infectious Disease and UN agencies, including UNAIDS, UNICEF and UNFPA.  

With 20 000 new HIV infections in 2017, Pakistan has the second fastest growing AIDS epidemic in the Asia Pacific region, with the virus disproportionately affecting the most vulnerable and marginalized, especially key populations. UNAIDS continues to work with the government and partners in Pakistan to strengthen the response in the country.

Ahmed (not his real name) is worried as he tells his story: his five-year old son Mukhtar has been newly diagnosed with HIV. Ahmed, a medical officer working in a local hospital in the city of Ratodero in southeast Pakistan, had taken Mukhtar to be tested for HIV when the local media began warning of an increase in HIV cases among children living in his area of Sindh Province.

At the end of April, following warnings from a medical practitioner in Ratodero that a number of children under his care had tested positive for HIV in a short span of time, health officials expanded HIV screening in Larkana District. After more than six weeks of testing, more than 750 people have been newly diagnosed with HIV, with children accounting for 80% of the confirmed cases. Ahmed’s son is one of them. Before the outbreak, just over 1000 children were living with HIV in the entire country. Although further investigations are being conducted to uncover the cause of the outbreak, experts say that poor infection control practices including a lack of sterilization and the re-use of syringes and drips, could be a factor.   

Mukhtar sits quietly in his father’s lap, as Ahmed continues to tell his story.

“When I told my wife, she started to ask me questions, where did this come from, why has this happened to my child and will my child survive.” Anxiety and fear have grown in Ahmed’s family and across the province.  Every day, hundreds of parents line up outside the screening sites and pour into hospitals and clinics to get their children tested. Many of them have little understanding of HIV.

As an immediate response to the outbreak, the Sindh AIDS Control Programme (SACP) has been carrying out a major testing campaign by expanding HIV testing hubs and establishing a new HIV testing facility at the Taluka Headquarter Hospital in Ratodero. These measures have enabled more than 26 000 people to be tested, mostly children.  Sindh’s Ministry of Health has also strengthened its efforts to prevent   unlicensed and informal medical practices from operating and, as a result, 900 health clinics and unlicensed blood banks have been closed.

To ensure immediate access to HIV treatment, a new antiretroviral treatment clinic for children has been established in Larkana and additional health care providers have been deployed. These efforts are saving lives, as 356 people, including Ahmed’s son, have already been enrolled in HIV care services and started antiretroviral therapy. “I was scared but then my child got the treatment he needed,” says Ahmed. “Now we need to ensure that ARV treatment will continue to be available in our district”.

The United Nations in Pakistan is working closely with the federal and provincial governments to provide on-site technical support to help local partners effectively respond to the HIV outbreak and reduce the impact of the crisis. With the full participation of the World Health Organization,  UNICEF, UNAIDS, UNFPA and other UN agencies, the United Nations is providing support for the implementation of the “Sindh HIV Outbreak Response Plan, May 2019-Apr 2020”, which includes short-term  and long-term steps to identify the causes of the HIV outbreak, address them and strengthen the continuum of HIV prevention, treatment, care and support services.

A team comprised of SACP and other national partners with support from the United Nations acted as first responders. Subsequently, international support and expertise was brought in at the request of the federal government, to carry out an epidemiological investigation to understand the source, extent and chain of HIV transmission and provide recommendations. The investigation, whose preliminary findings will be presented on June 14, is led by the WHO with support from the Aga Khan University (AKU), the Field Epidemiology and Laboratory Training (FELTP) Programme, UNAIDS, UNICEF, the Dow Medical University in Karachi, Microbiology Society of Infectious Disease in Pakistan. 

The United Nations is also supporting national partners to develop a community response plan which will engage communities at all levels to reduce prevailing stigma and discrimination and promote health education. SACP will train health workers on paediatric case management and awareness and health education sessions will be organized with the involvement of community led organizations and religious leaders. Training sessions for local media on responsible HIV reporting and coverage will also be carried out. “We need to make sure that the root causes of this outbreak are tackled to prevent such tragedies from happening again,” says Ahmed.

With 20 000 new HIV infections in 2017, Pakistan has the second fastest growing AIDS epidemic in the Asia Pacific region, with the virus disproportionately affecting the most vulnerable and marginalized, especially key populations. UNAIDS continues to advocate for a strengthened response to the epidemic.

“We need ongoing work with national and international stakeholders to effectively address the critical gaps in preventing new HIV infections and to guarantee the health and well-being of all people living with HIV in Pakistan, so that the country is not left behind in the effort to end AIDS,” says Maria Elena F. Borromeo, UNAIDS Country Director in Pakistan.  

GENEVA/ISLAMABAD, 10 May 2018— UNAIDS congratulates the Parliament of the Islamic Republic of Pakistan on the passage of the Transgender Persons (Protection of Rights) Bill, 2018. The bill is transformational for transgender people who, in the past, either had to live with formal identification papers which did not accurately reflect their gender  or go without identity papers. The change in the law will enable transgender people to apply for a driver’s license and passport. They will also be able to apply to the National Database and Registration Authority to have their records changed to reflect their gender.  

Transgender people frequently face discrimination when they are required to use identity documents, such as driver’s license and passport, that do not match their gender identity or gender expression. Transgender people have been denied access to services or support, for example in health care settings, because they do not have official identity documents that recognize their gender identity or gender expression.

The new bill is very important for transgender people because it gives them legal protection. The groundbreaking changes provide access to rights previously denied to transgender people. They will now be entitled to inherit property, have the right to vote in all national, provincial and local government elections and to run for public office. All without fear of discrimination. The bill also allows for measures that are designed to meet the specific needs of transgender people. This includes the establishment of protection centres and safe houses and special vocational training programmes.   

“This bill provides an enabling environment for transgender people to access health care, social justice, equality and dignity in society while enjoying productive lives,” said Michel Sidibé, Executive Director of UNAIDS. “This is a positive move that will support Pakistan in achieving the end of AIDS as a public health threat by 2030.”  

Transgender people have a HIV prevalence rate 7.1 percent in Pakistan.  Fifty-two percent of transgender people report facing stigma and discrimination. The figure increases to 55.8 percent for transgender sex workers.

The bill prohibits harassment of transgender people in the home and in public. It is now against the law for employers, educational institutions, health services, traders, public transport and property owners or sellers to discriminate transgender people in anyway.

“The passing of this bill is a dream come true for many transgender people,” said Bubbly Malik, Executive Director of the Wajood Society. “We have come a long way and fought hard to get this. We will not stop now. This is the first step towards empowerment.  We will be there to see its effective implementation. The bill addresses health, employment and educational services which makes me happy.” 

In June 2016, Member States of the United Nations committed in the Political Declaration on Ending AIDS to “promoting laws and policies that ensure the enjoyment of all human rights and fundamental freedoms for children, adolescents and young people, particularly those living with, at risk of and affected by HIV, so as to eliminate the stigma and discrimination that they face.”

UNAIDS urges all governments to fully implement the human rights of people living and affected by HIV, including by providing strong legal protections and implementing programmes to end discrimination and advance access to justice . 

The Pakistan Institute for Parliamentary Services (PIPS) and UNAIDS have signed an agreement to strengthen collaboration to protect the rights of people living with and most at risk of HIV. The Memorandum of Understanding was signed in Islamabad, Pakistan on 21 October by Zafarullah Khan, Executive Director, PIPS and Mamadou Sakho, UNAIDS Country Director for Pakistan and Afghanistan in the presence of Marriyum Aurangzeb, National Convener, Parliamentary Sustainable Development Goals.

With the new agreement UNAIDS and PIPS will work together to raise public awareness of Pakistan’s commitment to the AIDS response. They will also build the capacities of parliamentarians to find solutions for HIV-related problems at district level and to create a protective legal environment for an effective AIDS response. The partnership will also encourage parliamentarians to call for budgetary allocations for the AIDS response at the national and provincial levels.

During the signing ceremony, Ms Aurangzeb highlighted the importance of parliamentary oversight to advocate for the public’s basic health and education rights. She reiterated the strong resolve of the national parliament to take up a people-centric development agenda and improve the service delivery of government through legislation.

A photography exhibition portraying the inspirational stories of people living with HIV opened in Islamabad, Pakistan, on 7 September.

A Photo Story on People Living with HIV in Pakistan is a collection of 25 portraits of men and women living with HIV who have taken the decision to share their stories of HIV-related stigma with the public. It is the first exhibition in Pakistan to shine the spotlight on the resilience of people living with HIV. Each photo is accompanied by a short interview in which people express their challenges and concerns, but also their determination to bring about change and eliminate stigma and discrimination.

Nazir Masih, the Chief Executive Officer of the New Lights AIDS Control Society, a non-profit organization dedicated to providing treatment, care and support for people living with HIV, is one of the people portrayed in the exhibition. He said, “HIV is a problem of human beings and it is not an issue of any particular religion or nation. That is why hurdles and threats cannot deter me from the path of helping those in need and will not stop me, come what may, because this is what I have been made for.”

In Pakistan, it has often been difficult to disseminate key HIV information, owing to cultural and social barriers. The aim of this exhibition is to give a human face to the epidemic, with photographs that will have a lasting impact and can be shared on multiple platforms.

“We salute the courage and willingness of the men and women showcased in this exhibition to disclose their status in the hopes of transforming society,” said Steve Kraus, Director of the UNAIDS Regional Support Team for Asia and the Pacific, who inaugurated the exhibition. “Let us embrace our brothers and sisters living with HIV. Only when we reach zero discrimination can we end the AIDS epidemic in Pakistan.”

Stigma and discrimination towards people living with HIV remains a widespread challenge in Pakistan. The country’s People Living with HIV Stigma Index, conducted in 2010, revealed high levels of stigma and exclusion from families and religious activities and discrimination in employment. One third of respondents reported being denied access to health care in the previous 12 months.

Abdul Baseer Khan Achakzai, National Programme Manager, National AIDS Control Programme, said “The Government of Pakistan is committed to scaling up targeted interventions to prevent the rise in HIV prevalence among key and vulnerable populations and to fostering an organized national response to halt new HIV infections, improve the health and quality of life of people with and affected by HIV and initiate community-based HIV testing to bridge the gap between registered and estimated HIV cases.”

The exhibition was produced in collaboration with the National AIDS Control Programme of Pakistan, the United Nations Information Centre and UNAIDS.