HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak

Abstract

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.

Investigation of an extensive outbreak of HIV infection among children in Sindh, Pakistan: protocol for a matched case–control study

“…Nosocomial outbreaks of HIV infection have previously been reported in Pakistan and other countries, but have mostly been related to a specific health facility and have not been at this scale 5 11 12. In a report of the outbreak, we reported that the proportion of infants with an HIV-positive mother was significantly higher than that among older children, implying that vertical transmission may have contributed to transmission 3. Although there has been an unexpectedly high number of paediatric HIV diagnoses, it is by no means certain that the acquisition of infection by children was recent or from one source.…”

“…Although the HIV epidemic is mostly limited to key populations, outbreaks in the general population have occurred in previous years 4 8. The outbreak in Larkana, Sindh in 2019 is the largest reported to date and the first time that children have been predominantly affected 3. Although there has undoubtedly been a vigorous effort by the provincial and federal government and other stakeholders to implement an appropriate response to the outbreak, understanding the drivers and the evolution of the HIV outbreak is critical to inform coherent middle-term and long-term strategies to control the HIV epidemic in Pakistan.…”

“…It has been widely assumed that the HIV outbreak is due to parenteral transmission through the reuse of needles in healthcare settings, although vertical transmission may also play a role 3 9 10. This study is important to identify the primary mode of HIV transmission in this outbreak to tailor context-specific interventions.…”

“…As part of the response, the federal and provincial established an HIV screening camp at Tehsil Hospital Ratodero, a public-sector hospital, with voluntary counselling and testing offered to any individual attending the camp regardless of age. Between April and July 2019, 930 individuals tested HIV positive of whom 763 were children aged below 16 years 3. This constituted a 54% increase in the cumulative number of paediatric HIV diagnoses over the past 13 years.…”

Current Challenges of Digital Health Interventions in Pakistan: Mixed Methods Analysis

“…In 2011, after a particularly severe Dengue outbreak, a GPS-enabled mobile application called the Dengue Activity Tracking System (Punjab Information Technology Board) was developed to track suspected and confirmed cases of dengue [ 38 ]. In 2 recent epidemics of the extensively drug-resistant typhoid and human immunodeficiency virus (HIV) in the province of Sindh, geospatial mapping helped considerably with identifying the root causes of the outbreaks and with isolating cases and their spreads [ 39 , 40 ].…”