Topic: HIV prevention, test & treatment in Pakistan
Issue: Lack of access to HIV prevention, treatment, care & support services compromises the objective of “Close the Gap” in Pakistan
Pakistan is a developing country located in South Asia with over 130 districts, 796096 Sq KMs of area and over 18 billion of the population. Over 60% of the population resides in rural areas with very limited access to the basic facilities of the life. Major portion of the population is vulnerable to infectious diseases, natural calamities, poverty, starvation, lack of education and technical knowhow. Reportedly Pakistan stands at No.2 in the world as far as the Hepatitis –C infection is concerned and No.2 in HIV prevalence in South Asia. Though a lot of development has taken place to address the primary health care issues of the people but a lot more needs to be achieved and HIV epidemic is not an exception to this.
Like other Asian countries, Pakistan is following a comparable HIV epidemic trend having moved from ‘low prevalence, high risk’ to ‘concentrated’ epidemic in the early to mid-2000s among Key Affected Populations (KAPs), namely among PWIDs and sex workers. The 2011 IBBS conducted by the Government of Pakistan’s HIV/AIDS Surveillance Project (HASP) in 19 cities confirmed that HIV prevalence among Key Affected Populations continued to rise, with an average prevalence of 37.8% among PWIDs as compared to 20.8% in 2008; 1.6% among Male sex workers (MSWs) as compared to 0.9% in 2008; and 0.6% among Female sex workers (FSWs) as compared to 0.2% in 2007. Amongst ‘Hijra’ & Transgender sex workers prevalence was at 5.2% in 2011 lower than 6.1% in 2008.
As per recent available statistics Pakistan is one of those three (3) countries where HIV infection is on rise, including Indonesia and Philippines. There exits huge gap between estimated, registered and on treatment PLHIVs in Pakistan, which reflects low testing rates, centralized treatment facilities, lack of awareness and fear of stigma and discrimination. By 2012, as per UANIDS/WHO estimation modeling EPP (2013) the estimated total population of PLHIV in Pakistan was around 78,000. According to the NACP, by end October 2014 there were 12,126 PLHIVs registered in 18 ART centers. Out of these, there were 4742 PLHIVs are on ART including 4556 on 1st line and 186 on 2nd line. Looking at trends, there is a gradual increase in the number of persons registered at ART centers and those getting ART. The existing gaps illustrate a need to reach out the unreached, breaking down the barriers to access HIV prevention, treatments, care and support facilities, concrete action to eliminate stigma and discrimination which is as high as 48% as per the data collected under CAT-Study and meaningful involvement of community.
HIV Testing Facilities
In Pakistan majority of HIV testing facilities are mainly restricted to Governmental/public health centers. Selected public health centers/hospitals provide free of cost testing facilities for diagnoses of HIV. Community level services, through CHBC &CoPCs sites, in majority of cases, services as a source of initial contact with the community. These structures, in addition to other services, also provide rapid HIV testing. A client once diagnosed on rapid testing referred to nearest HIV treatment center or referral laboratory for subsequent confirmation. The country has recently adopted three rapid testing strategy, as per the WHO guidelines. Following the WHO and National ART Guidelines the diagnosed PLHIVs are asked to initiate the Antiretroviral Therapy (ART) with the CD-4 count 500 or below or as per the clinical assessment.
CD-4 & Viral Load (VL) Testing
The WHO and National ART Guidelines illustrate a need for conducting periodic CD-4 and VL tests after every three (3) months, however non scarcity of resources hinders these guidelines to be implemented and in most of the cases the clients are asked for CD-4 and VL test twice a year. But still this depends how many PLHIVs have access to the testing facilities. Lack of a testing infrastructure and availability of CD-4 and VL testing facilities at very few places/centers is major hindrance to conduct the tests as per WHO and national Guidelines. Though the tests are offered free of cost, however the patients have to manage for traveling costs to have access to testing facilities. As per the data collected under CAT-Study by the APLHIV 57.3% males and 62% female PLHIVs got their CD-4 test within six (6) months of diagnoses, whereas, 60.8% male and 45.6% female got VL test after diagnoses. Very recently the concept of point of care test which is through mobile CD-4 testing machines has been introduced which has not only proved to be very economical for the PLHIVs but has also given wider access to this test facility. The APLHIV has played a vital role in carrying out aggressive advocacy for procurement of such machines especially for far flung areas of Punjab, Sindh and Balochistan provinces. Currently seven (7) mobile CD-4 machines are providing the testing facilities in addition to some of the treatment centers. List of HIV treatment centers offering CD-4 and VL tests is attached as Annex-A.
As per the data available with National AIDS Control program (NACP), there are 18 treatment centers which are located in major cities, thus making the accessibility difficult for those who are at far distances from these cities and overloading of the patients in some of the treatment centers. Total PLHIVs registered are 12,126, out of which 4742 or taking ARVs with 4556 being on 1st line and 186 being on 2nd line. Lack of infrastructure, distances and expenses involved lack of qualified HIV doctors and non availability of testing and treatment facilities in far flung area is one of the major causes of the existing gap. As per the data of CAT-Study 39.5% delayed initiation of ARVs was recorded with major reason of centralized treatment facilities. However, in last one year or so a positive and responsive change has been noted in the attitude of the government to address these issues. The team at present at NACP is dedicated to facilitate the community and is working very closely with the APLHIV to enable maximum PLHIVs to access the treatment facilities. Close collaboration of the NACP and the APLHIV has resulted in establishment of new treatment centers at Faisalabad, Turbat and Rawalpindi. More efforts are needed to decentralize and further develop more the facilities, as per the need. The list of treatment centers is attached as Annex-B. NACP has recently introduced new ART guidelines, with clinician being trained on it. According to the new guidelines FDCs will be introduced from January 2015 onwards. Meanwhile, NACP has ensured third line of treatment as well.
Distances & Costs Involved To Access Treatment Facilities
As per the data collected under CAT-Study over 76% of the PLHIVs depend on treatment in public sector, 51.8% PLHIVs visit the treatment center on monthly bases. No data is available to know about the distances involved to access the treatment facilities but as per the data available under CAT-Study median distance to nearest treatment center from city/large town/small town is 120 minutes, from rural areas it is 200 minutes and traveling cost ranging from 300 to 1000 PKR, whereas PPTCT site from cities and large towns is ninety (90 minutes) and from rural area/small towns it has been recorded as 120 minutes. Travelling cost to reach PPTCT ranges from PKR 200 to 600 per trip. But we have to keep the limitation in mind that CAT Study recruited only 525 participants mainly from major cities/large towns, so this information may not truly reflect the distances and the traveling costs. The CATS study concluded number and geographical location of ART centers, as the main hindrance to access to HIV treatment service in Pakistan. The detail of PLHIVs registered, on treatment and on 1st& 2nd line is being attached as Annex-C.
An over whelming majority of the PLHIVs is on 1st line ART Drugs. The regimen followed in most of the cases is 4- 5 pills taken in 24 hours (BD doses). The ARVs are being provided free of cost on all treatment centers. Global Fund is the only donor agency providing funds for continued provision of ARVs. Based on the findings and recommendation of CAT-Study the APLHIV carried an advocacy to phase out Stavudine (Pakistan being the only country to use it in Asia Pacific region) due to its side effects. The NACP responded positively and now the Stavudine has been phased out from the regimens. More over fixed doze is being introduced shortly. The guidelines for fixed dose combination have already been finalized and training is being imparted to HCPs of the treatment centers. Currently following regimens are in use: –
Ziudovudine/Tenofovir+ Lamuvudin + Nevirapine
Ziudovudine/Tenofovir + Lamuvudin + Efavirenz
Ziudovudine + Lamuvudin + Nevirapine
Ziudovudine + Lamuvudin + Efavirenz
Ziudovudine/Tenofovir + Lamuvudin + Lopinavir/Ritonavir
Ziudovudine + Lamuvudin + Lopinavir/Ritonavir
Lamuvudin + Tenofovir + Nevirapine
Lamuvudin + Tenofovir + Efavirenz
Lopinavir + Ritonavir + Tenofovir
Visit to Treatment Center
To ensure an input of few PLHIVs registered at one of the (nearest) treatment center in this brief, The Project Coordinator GFATM Round-10 along with National Coordinator visited HIV treatment and care center located at Pakistan Institute of Medical Science-Shaheed Zulfiqar Ali Bhutto Medical University- Islamabad. Pakistan Institute of Medical Sciences (PIMS) is one of the modern, leading and well equipped health facilities located in the capital city of Islamabad. Through an MOU this hospital also houses an HIV treatment Center, which was established in 2006. The center has 1908 registered HIV patients from across the country. The most experience, learned and highly qualified doctor, Dr. Rizwan Qazi, heads this center. Almost all the doctors dealing with HIV across the country have been trained by Doctor Qazi. This center also houses a PPTCT center, a VCT room and testing lab. All the services from diagnosis to treatment are offered here. Hundred of Patients get follow-up checkups every week. A delectated team of doctors including Dr. Naila and Dr. Mona, Male Counselor Mr.Nadeem and Miss Mussarat female Counselor assist Dr. Qazi in his work. Treatment Center is equipped with all basic facilities to have detailed checkup of the patients, VCT room which not only is used for counseling but posses all basic information about HIV, written in English & Urdu. Medicines are kept here on slandered temperature. Lab is headed by Mr.Usman which offers all HIV related diagnostic tests as well as CD-4 and VL tests. Like other treatment centers manual as well soft form data of the patients is kept under strict control to ensure confidentiality. The center now in collaboration with APLHIV is also creating and increasing awareness about the HIV. During the visit couples of patients were interacted to get their feedback. The questions which were asked are attached as Annex-E.
The patients were generally found to be satisfied with the services being given at the treatment center. The patients were of the view that community based monitoring being implemented by the APLHIV has played a pivotal role in improving the services. The attitude of HCPs at the center was recorded to be good and friendly. In view of clients there was a need to provide some comfortable facilities in waiting area to manage the climatic severities and to keep the confidentiality. Through a systematic planning the efforts are being made at the center to ensure that all the clients undergo CD-4 and VL tests once in six (6) months. No issue about the stock out of ARVs was observed in last six (6) months, for which the clients gave credit to the APLHIV and the monitoring being carried out by the APLHIV. The treatment center enjoys good repute with community based organization engaged in provision of services to the community members. However the patients were uncomfortable as far as the access to the center and expenses involved are concerned.
Pakistan has serious issues to close the gap between those who have an access to HIV prevention, testing, treatments, care and support facilities and those who are left behind. As a matter of fact no one shall be ignored, neglected or left behind due to his/her HIV status. To close the existing gaps each one of us has to recognize his/her due role, fight the prejudice, improve the awareness/education, break the stigma and discrimination issues, address human rights breaches, ensure meaningful engagement of the community and above all have to ensure the accessibility of all PLHIVs to HIV prevention, testing, treatment, care and support facilities. We are not even near to the minimum required target of 40% PLHIV accessing the services. 18 treatment centers in a population of over 18 million with an estimated number of 78,000 PLHIVs is regrettable. The things turn out to be nastier when we find these facilities housed only in major cities, thus leaving those behind who do not have enough resources to access the services on regular bases. 18 treatments do not address even the needs of current register members. We have evidence based information where around 2000 PLHIVs are registered in one center. On average each treatment center is to house 4334 PLHIVs (78,000 estimated number/18 treatment centers) which renders it impossible to close the gap. Things are even worst in terms of testing facilities. Only few centers are equipped with facilities to provide CD-4 and VL test facilities. There are certain complaints received about the attitude of HCPs which is well expected if we compare the infrastructure and the number of patients. The testing and treatment facilities are being owned by the government in most of the cases, thus leaving a negligible share of private sector. If we need to minimize the gap we must engage communities for provision of services especially in community based testing, we need to decentralize the treatment centers to district level, and include Military Hospitals and facilities of CBOs/NGOs/CSOs can be used without much of investments. Such measures shall ensure getting maximum PLHIVs into services fold which shall also control new infections.
AVAILABILITY OF CD-4 & VL TESTING FACILITIES
|S/NO||TREATMENT CENTER||TESTING FACILITY AVAILABLE - CD-4||TESTING FACILITY AVAILABLE - VL|
|1||HIV treatment & Care Center PIMS-Islamabad||Yes||Yes|
|2||Aziz Bhattai Shaheed Hospital Gujrat||Yes||No|
|3||Jinnah Hospital Lahore||Yes||Yes|
|4||Civil Hospital Karachi||Yes||Yes|
|5||Chandka Medical College Larkana||Yes||No|
|6||Hayatabad Medical Complex Peshawar||Yes||In process|
|7||Bolan Medical College Quetta||Yes||No|
|8||District Headquarter Hospital Turbat||Yes||In process|
|9||Indus Hospital Karachi||No||In process|
TREATMENT CENTERS & THEIR LOCATION
|S/NO||NAME OF TREATMENT CENTER||LOCATION|
|1||HIV Treatment & Care Center-Pakistan Institute of Medical Sciences Islamabad||Islamabad|
|2||HIV Treatment & Care Center-Mayo Hospital -Lahore||Lahore|
|3||HIV Treatment & Care Center-Services Hospital Lahore||Lahore|
|4||HIV Treatment & Care Center-Jinnah Hospital Lahore||Lahore|
|5||HIV Treatment & Care Center-Allied Hospital Faisalabad||Lahore|
|6||HIV Treatment & Care Center-District Headquarters (DHQ) Hospital Sargodha||Sargodha|
|7||HIV Treatment & Care Center-DHQ Hospital D.G Khan||Dera Ghazi (DG) Khan|
|8||HIV Treatment & Care Center-Aziz Bhatti Shaheed Hospital Gujrat||Gujrat|
|9||Pediatric HIV Treatment & Care Center-Services Hospital Lahore||Lahore|
|10||Pediatric HIV Treatment & Care Center-Services Hospital Lahore||Lahore|
|11||HIV Treatment & Care Center-Indus Hospital Karachi||Karachi|
|12||Pediatric HIV Treatment & Care Center-Civil Hospital Karachi||Karachi|
|13||HIV Treatment & Care Center-Aga Khan Hospital Karachi (Private Hospital)||Karachi|
|14||HIV Treatment & Care Center-Civil Hospital Karachi||Karachi|
|15||HIV Treatment & Care Center-Chandka Medical College Hospital Larkana||Larkana|
|16||HIV Treatment & Care Center-Hayatabad Medical Complex Peshawar||Peshawar|
|17||HIV Treatment & Care Center-DHQ Hospital Kohat||Kohat|
|18||HIV Treatment & Care Center-Bolan Medical Complex Quetta||Quetta|
|19||HIV Treatment & Care Center-DHQ Hospital Turbat||Turbat-Ready to be launched|
DETAILS OF REGISTERED & ON TREATMENT PLHIVS
|S/NO||NAME OF TREATMENT CENTER||REGISTERED PLHIVS||ON TREATMENT|
|1||HIV Treatment & Care Center-Pakistan Institute of Medical Sciences Islamabad||1908||531|
|2||HIV Treatment & Care Center-Mayo Hospital -Lahore||451||88|
|3||HIV Treatment & Care Center-Services Hospital Lahore||354||78|
|4||HIV Treatment & Care Center-Jinnah Hospital Lahore||956||454|
|5||HIV Treatment & Care Center-Allied Hospital Faisalabad||438||251|
|6||HIV Treatment & Care Center-District Headquarters (DHQ) Hospital Sargodha||415||18|
|7||HIV Treatment & Care Center-DHQ Hospital D.G Khan||894||508|
|8||HIV Treatment & Care Center-Aziz Bhatti Shaheed Hospital Gujrat||618||310|
|9||Pediatric HIV Treatment & Care Center-Services Hospital Lahore||173||57|
|10||Pediatric HIV Treatment & Care Center-Services Hospital Lahore||398||145|
|11||HIV Treatment & Care Center-Indus Hospital Karachi||352||195|
|12||Pediatric HIV Treatment & Care Center-Civil Hospital Karachi||34||10|
|13||HIV Treatment & Care Center-Aga Khan Hospital Karachi (Private Hospital)||26||17|
|14||HIV Treatment & Care Center-Civil Hospital Karachi||2436||653|
|15||HIV Treatment & Care Center-Chandka Medical College Hospital Larkana||676||364|
|16||HIV Treatment & Care Center-Hayatabad Medical Complex Peshawar||1493||752|
|17||HIV Treatment & Care Center-DHQ Hospital Kohat||261||164|
|18||HIV Treatment & Care Center-Bolan Medical Complex Quetta||243||147|
|19||HIV Treatment & Care Center-DHQ Hospital Turbat|
QUESTIONNAIRE FOR PLHIV AT TREATMENT CENTER
- Do you find the basic facilities functional in the waiting area?
- What procedure you need to undergo before meeting the doctor?
- How much time does it take for you to meet the doctor?
- Does the doctor give you appropriate time and attention?
- Are you comfortable to share your issues with doctor?
- Are you dealt in dignified manner by the doctor?
- Are you treated properly for the complaints and health related problems by the doctor?
- Do you think your record is kept confidential at the treatment Center?
- Do you face any stigma/ discrimination because of your HIV status while being entertained by the doctor?
- How do you find the counseling services at the treatment Center?
- Is the attitude of health care providers friendly?
- After how much time your CD4 and Viral load tests are conducted?
- How much distance is involved between your home & treatment center?
- Did you find any stock outs of ART in last three months?
- Are you provided with information about STIs and OIs?