Getting your Trinity Audio player ready...
|
M
ariam had been experiencing body aches and on-and-off fever for a month but resisted going to a doctor. A friend was finally able to convince her to do so last January, and she was made to undergo some tests. The diagnosis was as she feared: she has HIV.
Her relatives and neighbors who have somehow learned about her test result now shun her and believe she had gotten infected because she had slept around. But the 35-year-old widow swears she had not. It is possible that she got the deadly virus from her husband who was a drug addict and died last year.
But Mariam thinks that the more likely reason is that one of the local doctors she had visited in previous months had used a dirty syringe.
It’s not a far-fetched theory. After all, international and local health experts have determined that unsafe medical procedures or treatment are among the main drivers in the spread of HIV in Pakistan.
More specifically, the apparent rampant reuse of syringes and needles not only by Pakistan’s teeming quacks but even by some licensed doctors has emerged as a significant vector in HIV spread in the country.
This is exacerbated by the preference of many Pakistanis for injections and intravenous (IV) drips instead of oral medication. The popular assumption is that since the medicine goes directly into the bloodstream with IVs and injections, the patient will be cured quicker, if not immediately.
“The situation is quite serious,” Dr. Fatima Mir, associate professor at Aga Khan University in Karachi, tells ADC. “Women of reproductive age and children appear to be particularly vulnerable to parenteral acquisition through unsafe injections, procedures or blood. This is especially true for high-prevalence districts in Pakistan.”
Pakistan’s own National Institutes of Health (NIH) acknowledges that the predominantly Muslim South Asian country “stands only a few steps behind India and Nepal in terms of HIV epidemic.”
In the past seven years alone, there has been a 70-percent increase in HIV cases in Pakistan. Last December, the Ministry of National Health Services and Regulations revealed that Pakistan had more than 9,000 new HIV/AIDS cases recorded in 2023. Experts say, however, that only 23 percent of those with HIV in Pakistan are aware that they have it.
The HIV/AIDS Data Hub for Asia-Pacific puts the number of people living with HIV in the country at 270,000. It also says that this figure is rising, and so are HIV/AIDS-related deaths.
Yuki Takemoto, country director for the Joint United Nations Programme on HIV/AIDS (UNAIDS) in Pakistan, tells ADC: “There has been a six-fold increase in AIDS-related deaths since 2010 in Pakistan.”
A pediatric HIV outbreak
In Ratodero, an impoverished town in Sindh province’s Larkana District, where Mariam lives, “the positive cases are coming on a daily basis,” says Dr. Ghulam Shabbir Imran Arbani.
“Every day if 10 samples were sent for tests, one to two come out as positive,” he says. “The positive screening ratio is 10 percent in Ratodero and adjoining areas. The quacks are operating now and using manual syringes, which is the main factor of spreading HIV.”
Some five years ago, Arbani had sounded the alarm in Ratodero after the apparent reuse of syringes and needles there had led to a pediatric HIV outbreak.
Many of the cases were traced back to Muzaffar Ghanghro, a government pediatrician who was popular in the community for the low fees he charged at his private clinic. Ghanghro was arrested and detained on charges of negligence, manslaughter, and causing unintentional harm. A medical exam was ordered done on him, which revealed he had HIV himself. But he said that he had no idea he had the illness. He also denied reusing syringes.
Ghanghro spent two months in detention before he was eventually released on bail. In 2022, he was acquitted of all charges.
Since the news on the Ratodero pediatric HIV cases first broke in April 2019, the community has logged more than 2,100 residents – many of them children – testing positive for the virus, among whom more than 200 are now dead.
In November 2019, largely in reaction to the Ratodero outbreak, the central government announced a ban on conventional syringes; instead, single-use or auto-disable syringes would be used. Up to now, however, authorities have been unable to fully enforce the ban. In the meantime, many Pakistanis continue to expect the needle whenever they seek treatment – and the health providers, quacks and otherwise, see no reason for not using it.
According to a 2006 study, the number of injections per person per year in Pakistan had been estimated to be in the range of 8.2 to 13.6, “one of the highest in the developing world.” The study, which was on the cost of unsafe injections in the country, added: “Extrapolating this number to the whole country would result in 1.5 billion injections per year. Approximately 4 percent (75 million) of these are administered for immunization while the remainders are used for therapeutic use. Of these, 94.2 percent are unnecessary.”
Another 2006 study, this time on population beliefs on the efficacy of injections in Sindh province, observed: “In Pakistan, people’s lack of awareness of risks associated with injections and their strong belief in the fast action of injections are driving injection overuse. These factors are supplemented by general practitioners’ and unqualified providers’ inclinations to prescribe more injections.”
No lessons learned
Research done 14 years later would reveal that little had changed. A 2020 study on the reuse of syringes noted that “both providers and patients felt that injections were needed for common ailments,” and that 38 percent of the providers “were likely to reuse syringes during injections.”
According to the researchers, the patients did not know that the syringes were being reused, and that reuse was done “just as often by physicians or non-physicians and … irrespective of sex of providers or the fee charged.”
The study’s researchers recounted what they saw out on the field in Tando Allahyar in Sindh and Rawalpindi in Punjab: “Syringe reuse happens against a backdrop of frequent injections. Around 38 percent of injection providers procure too few syringes for the injections that they provide and will likely reuse consistently. They also see more patients and give more injections. They charge slightly less per visit than providers that do not reuse syringes; however, their fees remain largely the same whether or not they give an injection. These providers stock a median of five syringes and give 14 injections daily; meaning that each syringe is reused two or three times.”
All three studies underlined that such beliefs and the rampant reuse of syringes and needles were putting people at risk of contracting HIV, as well as other blood-borne diseases.
Yet despite the highly publicized case in Ratodero, many Pakistanis have yet to connect injections to HIV. Instead, most associate it with “immoral activities” and drug use, which stigmatizes those who end up with the virus.
This is why Mariam is now being shunned by her own relatives, even though they had personally witnessed, as residents of Ratodero, themselves they had front-row seats to the the aftermath of the pediatric HIV outbreak caused by dirty needles there. There is also a persistent belief that merely being in close or constant contact with someone living with HIV heightens one’s risk of infection.
“I am constantly living in fear of dying anytime,” Mariam says. “I am facing social isolation and everyone has abandoned me.”
Muzaffar Ghanghro, the doctor who was blamed for many of the Rotadero HIV spread among children in 2019, has had much better luck in comparison.
Although local officials had been quick to point a finger at Ghanghro for the outbreak, some later said that other factors could have played a part. An October 2019 report in the U.S. online publication The Hill said: “Health officials say that Ghanghro is not likely to be the sole cause of the outbreak, noting that visiting health workers saw many other doctors reuse syringes, barbers use the same razors to shave customers, and roadside dentists use unsterilized tools.”
At the height of the controversy, there were even reports that Ghanghro had used the same drip for some 50 children without changing the needle. Yet when trial time came, no one came forward to support the charges against him in court.
Muhammad Zia, a police official at Ratodero, confirms that “nothing was found” against Ghanghro.
“The court has acquitted me in this false case in 2022,” Ghanghro, who is still a government doctor, tells ADC. “During the court proceedings no witness came against me and judge declared that there was no evidence found in this case against me. After the acquittal no appeal was filed by anyone.”
“My clinic is still open and I am still practicing at my ‘Shiraz Clinic’ in Ratodero,” he says. “The entire city is coming to my clinic and roughly I am dealing with more than a hundred patients every day. Dr. Arbani, in jealousy, trapped me in this case. He is a urologist and has nothing to do with this field.” ◉