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Truth and shame

What needs to be done to prevent the spread of HIV-AIDS in Pakistan?

Truth and shame

Human Immunodeficiency Virus (HIV) that produces Acquired Immunodeficiency Syndrome (AIDS) has been detected in patients in Pakistan. At present the estimated number of people infected is around one hundred and fifty thousand. This is probably an optimistically low estimate.

In some of my previous articles in which I discussed Hepatitis C (Hep C) I had also worried about HIV since both these viruses are spread in a similar fashion. We already have millions of people infected with Hep C in Pakistan; my fear has been that once HIV gets established in any group in Pakistan, it could also spread in the same fashion and to the same degree as Hep C.

Among other things the one similarity between HIV and Hep C is that the initial infection in both is quite mild and is often ignored. However, the virus stays in the body and its worst effects appear many years later and by that time even though treatment is possible, it is much less effective.

The best treatment for both is of course prevention but once infected it is important to have early diagnosis and treatment. The only way that happens is if persons who suspect that they might be infected get tested. It is important to point out that once both these infections were thought to be incurable and they still are but newer medicines can control the infecting virus and keep the infected person in reasonably good health for many, many years.

As I read about HIV-AIDS in the Pakistani newspapers these days I remember the early years of my practice of surgery in the United States. As Yogi Berra the great American folk philosopher and Yankee hall of fame baseball player said famously, “it’s deja vu all over again”.

During the early eighties we still had no idea about the mysterious disease that was killing so many young men and once we got a name and a cause for it, the question became how to prevent it since initially there was no treatment for it and once infected death was thought of as inevitable. And as surgeons we had a hard time making sure that we did not get infected while treating patients with this disease. Some of my surgical colleagues during those early years refused to operate on patients with HIV-AIDS.

During my years in Pakistan, we had to worry about getting infected with Hep C during surgery and we had to take similar precautions as we learned to take all those years ago against HIV. Of course, all patients that underwent major surgery in my department in Mayo Hospital were tested for Hep C prior to surgery and so we knew when to take special care.

What then needs to be done to prevent the spread of HIV? First of course are things that can be done through official regulations. The most important is the establishment and use of proper blood banks where all blood is checked for Hep C as well as HIV. Then comes the control of medical practitioners that are involved in using unsterile needles for multiple injections.

So now back to the similarities between HIV and Hep C. The long time between infection and the appearance of significant problems I have mentioned above. But more important are the methods in which these two viruses are transmitted from one person to another. The only way is if the body fluids from an infected person come in contact with the blood of another person.

Before I go to the exact methods of transmission of HIV and Hep C, let me make it very clear that normal contact like shaking hands, hugging, sharing a work space or toilets and using same utensils that have been washed does not transmit these viruses. The contact has to be between infected fluids and blood.

In the US before we had a name for it, HIV-AIDS was called the ‘gay plague’. And the commonest method of transmission was ‘unprotected’ sex between men. Over the years other methods of transmission became known and of these the most important for us as surgeons was transfusion of blood from an infected person. Next came drug addicts that used intravenous drugs and often shared needles. Unscrupulous medical ‘practitioners’ that used the same needles or surgical and dental instruments on different patients without sterilising them properly in between uses became a distant and rare cause.

The US Center for Disease Control (CDC) on its website presents the data about transmission of HIV for the year 2016. In this presentation, of almost forty thousand new cases of HIV, almost 90 per cent are due to sexual transmission and of these a vast majority from sex between men. When anybody discusses HIV in a public forum, sexual transmission is ignored as if it cannot happen in Pakistan. Indeed our rampant population growth is evidently almost entirely based on asexual activities.

That said, a recent newspaper report (Thousands screened for AIDS/HIV in ongoing campaign — Daily Times, Jan 6, 2018) did give some indication that the importance of sexual transmission in HIV and other such diseases including Hep B and C, and Syphilis is being considered as an important factor. This news item also reported that the Punjab AIDS Control Programme tested 24,000 bus and truck drivers, 47,000 prisoners, and 2,500 transgender persons in the year 2017.

The one thing common in this group is no visitations with medical quacks using the same needles for multiple injections. Unfortunately, the newspaper report did not mention the number of persons that tested positive for any of these conditions. I suspect that the number of people infected with these sexually transmitted diseases (STDs) was probably uncomfortably high as far the ‘authorities’ are concerned.

While discussing Hep C in the past I have emphasised that sexual transmission of Hep is an important factor and must be considered in any prevention campaign. The same is truer for HIV-AIDS. After sexual transmission the next most frequent method of HIV transmission is sharing of needles among intra-venous (IV) drug abusers. And now in the modern medical world, the least frequent method of transmission is tainted blood transfusion. In the Pakistani context, medical practitioners using unsterile needles for multiple injections in different people remain a distant fourth.

What then needs to be done to prevent the spread of HIV? First of course are things that can be done through official regulations. The most important is the establishment and use of proper blood banks where all blood is checked for Hep C as well as HIV. Then comes the control of medical practitioners that are involved in using unsterile needles for multiple injections especially intravenous infusions (iv ‘bottles’). However, the two most common causes of HIV transmission are the most difficult to control. These are ‘unprotected’ (without condom) sex and needle sharing among drug addicts.

The US experience clearly demonstrates that education about safe sex is important in prevention of HIV transmission but is not equally effective among the less educated and the poorer segments of society. As far as drug abuse is concerned, that is difficult to control. Unfortunately, the only way to control drug addiction is to legalise it and bring it out of the shadows. And that is not going to happen any time soon.

A major problem with diagnosis and treatment of HIV-AIDS is the ‘shame’ factor associated with this disease. A verse from the great Urdu poet, Parveen Shakir puts it in perspective. “Baat to sach hai magar baat hai rusva’ee kee” (True it is but it is a cause for shame).

 

Syed Mansoor Hussain

syed mansoor hussain
The author served as professor and chairman, department of cardiac surgery, King Edward Medical University.

One comment

  • “Unscrupulous medical ‘practitioners’ that used the same needles or surgical and dental instruments on different patients without sterilising them properly in between uses became a distant and rare cause.”

    I’m surprised you judge this to be rare. There have been several serious outbreaks in recent years. There are the examples of Adiyyila Jail and Swabi Jails, also in Faisalabad, Larkana and Chiniot. Some of the outbreaks mention significant numbers of people infected with HIV. Several villages around Sargodha, also Bhattiwala and Danish School in Punjab have all been mentioned in connection with healthcare associated HIV transmission.

    Investigations may not always be thorough but they may have been carried out by people who had an interest in not finding any evidence of unsafe healthcare practices. Perhaps HIV transmission through unsafe healthcare practices, by quacks and by some professionals, is just rarely identified and even more rarely investigated?

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