Background: In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. A cross-sectional study to understand the clinical profile of children who registered for HIV care was performed. Methods: Age-and sex-stratified HIV prevalence among individuals screened was estimated. Data on children who registered for HIV care including clinical history, HIV disease stage, Hepatitis B and C status and CD4 count was abstracted from clinical records and analysed using percentages and chi square tests. Findings: Between April-July 2019, 31,239 individuals underwent HIV testing of whom 930 tested HIV-positive. Of these, 763 (82•0%) were aged <16 years. Estimated HIV prevalence was 3.0% overall; 7.4% (283/3803) in children aged 0-2 years, 5.9% (321/5412) in children aged 3-5 years, and 1•3% (148/11251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 80.9% (478/591) were ≤5 years, 64•1% (379/591) were male and 53•4% (315/590) had a weight-forage Z-score <-3. Hepatitis B surface antigen and Hepatitis C antibody positivity was 8•4% (48/574) and 2•6% (15/574) respectively. Of children whose mothers tested for HIV, only 39/371 (10•5%) had HIV-positive mothers. Most children (89•2%, 404/453) reported multiple previous injections and 40/453 (8•8%) reported blood transfusions. Interpretation: This is an unprecedented HIV outbreak among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. Epidemiological and molecular studies to understand the full extent of the outbreak and its drivers are needed to guide HIV control strategies.
Background There has been a recent spate of mobile health (mHealth) app use for immunizations and other public health concerns in low- and middle-income countries. However, recent evidence has largely focused on app development or before-and-after effects on awareness or service coverage. There is little evidence on the factors that facilitate adoption of mHealth programs, which is critical to effectively embed digital technology into mainstream health systems. Objective This study aimed to provide the qualitative experiences of frontline health staff and district managers while engaging with real-time digital technology to improve the coverage of routine childhood immunization in an underserved rural district in Pakistan. Methods An Android-based app was iteratively developed and used for a 2-year period in 11 union councils of the Tando Muhammad Khan district, an underserved rural district with poor immunization coverage in Pakistan. We used iterative methods to examine the (1) acceptability and operability of the app, (2) validity of the collected data, and (3) use of the collected data. In addition, we collected the barriers and enablers for uptake of the mHealth app. Each of these topics was further explored related to changes in work as well as the enabling factors for and barriers to app use. In-depth interviews were conducted with the 26 vaccinators posted in the 11 union councils and 7 purposively selected key informants (government district managers) involved with the Expanded Program for Immunization. Findings were triangulated in line with the three broad research areas. Results Digital immunization tracking was considered acceptable by vaccinators and district managers. Real-time immunization data were used to monitor vaccination volume, track children with incomplete vaccinations, develop outreach visit plans, correct existing microplans, and disburse a fuel allowance for outreach sessions. The validity of the app data was perceived to be superior to that of data from manual records. Ease of operability, satisfaction with data, personal recognition, links to field support, and a sense of empowerment served as powerful enablers. Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints. An unintended knock-on effect was improved coordination and strengthening of Expanded Program for Immunization review platforms across district stakeholders through digitalized data. Conclusions Embedding digital technology into mainstream health systems relies on use by both end users and district stakeholders. Ease of operability, satisfaction with data reliability, personal recognition, links to field support, and empowerment are powerful enablers, whereas improved coordination as a result of easy, transparent data access can be an important by-product of digitalization. Findings are relevant not only for wide-scale implementation of immunization tracking apps in Pakistan but also for informing the use of digital technology for results-based delivery by frontline health workers.
IntroductionIn April 2019, 14 children were diagnosed with HIV infection by a private healthcare provider in Larkana district, Sindh province, Pakistan. Over the next 3 months, 930 individuals were diagnosed with HIV, >80% below 16 years, the largest ever outbreak of HIV in children in Pakistan. In this protocol paper, we describe research methods for assessing likely modes of HIV transmission in this outbreak and investigate spatial and molecular epidemiology.Methods and analysisA matched case–control study will be conducted with 406 cases recruited. Cases will be children aged below 16 years registered for care at the HIV treatment centre at Shaikh Zayed Children Hospital in Larkana City. Controls will be children who are HIV-uninfected (confirmed by a rapid HIV test) matched 1:1 by age (within 1 year), sex and neighbourhood. Following written informed consent from the guardian, a structured questionnaire will be administered to collect data on sociodemographic indices and exposure to risk factors for parenteral, vertical and sexual (only among those aged above 10 years) HIV transmission. A blood sample will be collected for hepatitis B and C serology (cases and controls) and HIV lineage studies (cases only). Mothers of participants will be tested for HIV to investigate the possibility of mother-to-child transmission. Conditional logistic regression will be used to investigate the association of a priori defined risk factors with HIV infection. Phylogenetic analyses will be conducted. Global positioning system coordinates of participants’ addresses will be collected to investigate concordance between the genetic and spatial epidemiology.Ethics and disseminationEthical approval was granted by the Ethics Review Committee of the Aga Khan University, Karachi. Study results will be shared with Sindh and National AIDS Control Programs, relevant governmental and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals.
In the absence of robust testing programs, timely and detailed outbreak reporting is essential for HIV control.
Background: In April 2019, an HIV outbreak predominantly affecting children occurred in Larkana District, Sindh, Pakistan. By December 2019, 881 of 21962 children screened had tested positive for HIV. We conducted an individually-matched case-control study to assess factors associated with HIV infection.Methods: Between July and December 2019, 406 cases (defined as individuals aged <16 years registered for pediatric HIV care in Larkana city) and controls (individuals without HIV matched 1:1 by age, sex and neighbourhood) were sampled concurrently. An intervieweradministered questionnaire was used to collect data on possible risk factors for HIV acquisition and a blood sample was collected from all participants for hepatitis B and C serology. Mothers of all participants underwent HIV testing. Odds ratios were estimated using conditional logistic regression to assess factors associated with HIV infection.Findings: Of 406 case-control pairs recruited, 401 were analyzed. The prevalence of hepatitis B surface antigen and hepatitis C antibodies was 18•2% (95% CI 14•5-22•3) and 6•5% (95% CI 4•3-9•4) respectively among cases, and 5•2% (95% CI 3•3-7•9) and 1•0% (95% CI 0•3-2•5) respectively among controls. Overall, 7.1% mothers of cases and no mothers of controls were HIV positive. In the 6 months prior to recruitment, 226 (56•4%) cases and 32 (8•0%) controls reported >10 injections, and 291 (72•6%) cases and 78 (19•5%) controls had received an intravenous infusion. At least one blood transfusion was reported in 56 (14•0%) cases and 3 (0•8%) controls in the past two years. HIV infection was associated with history of more injections and infusions (adjusted OR (aOR) 1•63; 95% CI 1•30-2•04, p<0.0001), blood transfusion (aOR 336•8; 95% CI 23•69-4787, p<0.0001), surgery (aOR=399•75, 95% CI 13•99-11419, p=0•0005), the child's mother being HIV positive or having died (aOR=3•13, 95% CI 1•20-8•20, p=0•0202). and increased frequency of private clinic and government hospital visits (p<0•0001), adjusting for confounders.Interpretation: The predominant mode of transmission in this outbreak was parenteral, likely due to unsafe injection practices and poor blood safety.
BACKGROUND There has been a recent spate of mobile health (mHealth) app use for immunizations and other public health concerns in low- and middle-income countries. However, recent evidence has largely focused on app development or before-and-after effects on awareness or service coverage. There is little evidence on the factors that facilitate adoption of mHealth programs, which is critical to effectively embed digital technology into mainstream health systems. OBJECTIVE This study aimed to provide the qualitative experiences of frontline health staff and district managers while engaging with real-time digital technology to improve the coverage of routine childhood immunization in an underserved rural district in Pakistan. METHODS An Android-based app was iteratively developed and used for a 2-year period in 11 union councils of the Tando Muhammad Khan district, an underserved rural district with poor immunization coverage in Pakistan. We used iterative methods to examine the (1) acceptability and operability of the app, (2) validity of the collected data, and (3) use of the collected data. In addition, we collected the barriers and enablers for uptake of the mHealth app. Each of these topics was further explored related to changes in work as well as the enabling factors for and barriers to app use. In-depth interviews were conducted with the 26 vaccinators posted in the 11 union councils and 7 purposively selected key informants (government district managers) involved with the Expanded Program for Immunization. Findings were triangulated in line with the three broad research areas. RESULTS Digital immunization tracking was considered acceptable by vaccinators and district managers. Real-time immunization data were used to monitor vaccination volume, track children with incomplete vaccinations, develop outreach visit plans, correct existing microplans, and disburse a fuel allowance for outreach sessions. The validity of the app data was perceived to be superior to that of data from manual records. Ease of operability, satisfaction with data, personal recognition, links to field support, and a sense of empowerment served as powerful enablers. Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints. An unintended knock-on effect was improved coordination and strengthening of Expanded Program for Immunization review platforms across district stakeholders through digitalized data. CONCLUSIONS Embedding digital technology into mainstream health systems relies on use by both end users and district stakeholders. Ease of operability, satisfaction with data reliability, personal recognition, links to field support, and empowerment are powerful enablers, whereas improved coordination as a result of easy, transparent data access can be an important by-product of digitalization. Findings are relevant not only for wide-scale implementation of immunization tracking apps in Pakistan but also for informing the use of digital technology for results-based delivery by frontline health workers.
The purpose of the study is to identify the crimes perpetrated by young offenders in the interior districts of Sindh, including Shikarpur, Sukkur, Dadu, and Ghotki, as well as to investigate the underlying causes of criminal behavior. This qualitative study was undertaken by collecting FIRs from four districts using random sampling. The sample consists of 485 FIRs of convicted young male offenders from 2019 to 2020. The study found that youth are involved in various crimes such as murder, rape, larceny, assault, drug/alcohol consumption, and illegal weapon possession. In addition, the study's indings identiied the factors that inspire young offenders to commit crimes, including poverty, land conlicts, tribal feuds, provocation, retaliation, sexual passion, and thrill. Consequently, illegal activities, as opposed to more constructive ones, are gaining popularity among the younger generation; therefore, the study suggests establishing a parental care and control program to improve educational and training facilities, increase employment opportunities, decrease the availability of dangerous weapons and drugs and alternative methods of crime prevention should be implemented.
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