In the year 1981, I joined one of the larger private hospitals in the city of Newark in New Jersey as a consultant (attending) in cardiac and thoracic (chest) surgery. One of my most vivid memories of my first year on staff was of being called to the medical intensive care unit (ICU) to try and save the life of a young man who was dying from an ‘unusual’ infection that had almost completely destroyed his lungs.
He was on a breathing machine with high pressures and had just collapsed both of his lungs, a fatal complication. When I saw the patient, I immediately cut open both sides of his chest to put in tubes to re-expand his lungs. And no, I did not even wait to put on a pair of gloves while performing this life-saving procedure.
After performing the procedure I noticed that the young man’s skin was covered with purple tumours. I asked my medical colleagues about what was wrong with the patient. They didn’t really know except that many patients were turning up with similar problems and most of them were intravenous drug abusers. The city of Newark where I was working was particularly afflicted by this disease. Sadly, the patient mentioned above died soon thereafter in spite of the best antibiotic therapy available.
It took a few years before the cause for this problem was discovered and the disease got a name. It was of course what we know today as infection with the Human Immunodeficiency Virus (HIV) leading to Acquired Immunodeficiency Syndrome (AIDS). In the early years of the HIV-AIDS epidemic it seemed that this was an inevitably fatal disease and the major emphasis was on prevention.
Three major reasons for transmission of this disease were established. First was the use of un-sterilised injection needles shared by intravenous (IV) drug abusers already infected with those not infected as yet. Second was ‘unprotected’ sex between infected and non-infected individuals. Third was the transfusion of infected blood. Perhaps one of the most famous ‘victims’ of HIV-AIDS to get infected from a ‘tainted’ blood transfusion was the great American tennis player, Arthur Ashe.
Before I go any further, let me say that today, HIV-AIDs is not only preventable but also eminently treatable but not yet curable. The most important developments in the prevention and treatment of this disease are medicines that, as some of the latest research demonstrates, can prevent infection in high risk populations. And those that are infected can be treated effectively to prolong life.
However, prevention remains the primary goal. This includes the emphasis on ‘protected’ sex especially the use of condoms, and the use of clean needles for IV drug abusers. One of the original ideas that this disease can only be transmitted during ‘homosexual’ sex between men has been discredited especially from the African experience where female partners of infected males are quite susceptible to this infection.
The most important thing to consider is that ‘medical’ treatment is still very expensive and the cost of ‘cocktail’ of drugs that infected patients receive every day is probably beyond the economic capability of most people in developing countries like Pakistan. HIV-AIDS might not yet be on the radar as far as Pakistan is concerned. But we already have a disease that is spread in a similar way as HIV-AIDS that is already ‘endemic’ in Pakistan. That is of course Hepatitis C (Hep C).
Based upon data available, as many as five to ten per cent of the population of Pakistan is infected with Hep C. And even though this disease can be controlled with medications, a vast majority of those infected either don’t know that they are infected or else do not have the wherewithal to pay for treatment. The important thing to remember about both these diseases is that even after infection it takes many years before the symptoms start to appear and by that time it is often too late to do much at least as far as Hep C is concerned. The interesting question is how so many people in Pakistan got infected with Hep C.
Hep C and HIV-AIDS spread quite the same way. Through the use of unsterilized needles, unprotected sex and tainted blood transfusions. But when we look at the US experience, as soon as the virus causing AIDS was discovered, stringent testing was put in place for blood being collected and used for transfusion. As far as needles shared by intravenous drug abusers is concerned, this still remains a problem but the public education about unprotected sex did make a major difference.
In Pakistan, tainted blood transfusions and unprotected sex are problems but the major way that Hep C is being spread is through unsterilized needles, not those used by drug addicts but rather those used by medical ‘quacks’ and ‘roadside’ dentists. One of the saddest part of my practice as a cardiac surgeon in the public sector was to see young men and women barely in their teens that would come in with advanced heart problems and turned out to be positive for Hep C.
None of these young people were infected because of unprotected sex or previous blood transfusions but all of them had been treated by medical ‘quacks’ and received multiple injections as treatment. And that all the ‘injections’ they received besides being of dubious medical efficacy were most likely given with unsterilized reused needles. This unfortunately is one of the major reasons for our Hep C epidemic in Pakistan.
That brings me to the problem of HIV-AIDs in Pakistan. Two recent news reports have me worried. First was from a Punjab minister who said that after being tested ‘only’ three hundred inmates in Punjab jails were found to be infected by HIV. The second was about a person deported from the Mideast who later found out that he was deported because he tested positive for infection with HIV.
First about the incidence of HIV positive inmates in Punjab jails. It is well known that sexual interaction between incarcerated men in jails is a reality. However, the minister talking of the infected inmates said nothing about how spread of HIV between the infected inmates and other inmates was going to be prevented. Clearly the Punjab government is not going to give out condoms to the jailed population.
As far as the person deported for being infected, that tells us that this infection is present in our population even in non-drug abusers. This is the most dangerous aspect of this disease. Once it enters the general population among supposedly healthy individuals, then it will spread for all the reasons that Hep C spread before it. And that is a nightmarish scenario. Especially since it takes many years between infection and the appearance of symptoms and by that time the infected person could well have infected many others.
Prevention is going to be difficult but should at least be attempted. This will require strict control over blood banks, elimination of the non traditional medical providers especially those that use injections unnecessarily and of course sex education. The last even conceptually is the most problematic.