Professional Documents
Culture Documents
We would like to acknowledge the efforts for these individuals who provided
immense support in developing this special supplement on HIV/AIDS. Mr. Fayyaz
Pirzado and Dr Henna Qahir for conducting search of articles. Mr. Agha Wali for
typing the articles and Mr. Saleem Ahmed for formatting the supplement.
Sten Vermund
Vanderbilt University Institute of Global Health, Nashville, USA.
Arshad Altaf
Canada-Pakistan HIV/AIDS Surveillance Project, Islamabad, Pakistan.
Sibylle Kristensen
University of Alabama at Birmingham, USA.
Rafique Khanani
Dow University of Health Sciences, Karachi, Pakistan.
Supported by training grant 7D43 TW01035-07 from the Fogarty International Center, National Institutes of Health (USA).
JPMA
The Journal of the Pakistan Medical Association (Centre)
Editorial Board
Chairman Members
Badar Siddiqi Aamir M. Jafarey Nadeem Rizvi
Abbas Zafar Nilofar Safdar
Editor-in-Chief Amin A. Gadet Najeeb-ul-Haq
Fatema Jawad Afia Zafar Najma Amjad
Anwar Ali Siddiqui Rashid Ahmed
Associate Editor-in-Chief A.R. Jamali Rifat Rehmani
Huma Qureshi Asad Pathan Rumina Hasan
Ayesha Mehnaz Saeed Hamid
Managing Secretary
Durre Samin Akram Sadia Ahsan
Abdul Bari Khan
Hamid Javaid Qureshi Salman N. Adil
Humaira Ahsan Shereen Bhutta
Associate Editors
Inam Pal Saeed Mahmood
Qudsia Anjum Fasih
Iqbal Afridi Shaukat Ali
Bilal Jamil
Javed Kazi Tahir Shamsi
Javaid Hassan Niazi Tasnim Ahsan
Editor, Students’ Corner
Mehreen Baloch Manzoor Hussain Yasmeen Bhurgri
Mirza Naqi Zafar Zahid Anwar Khan
Marketing Manager Mohammed Wasay Zarnaz Wahid
Salim Ahmed Mahmood Yousuf Zohra Zaidi
Statistical Reviewer
Aamir Omair
The Journal of the Pakistan Medical Association (JPMA) is published monthly from PMA House, Aga Khan
III Road, Karachi-74400, Pakistan.
All articles published represent the opinion of the author and not reflect official policy of the journal. All
rights are reserved to the Journal of the Pakistan Medical Association. No part of the Journal may be
reproduced, stored in a retrieval system, or transmitted in any form or by any other means, electronic,
mechanical, photocopying, recording or otherwise, without prior permission, in writing, of the Journal of
the Pakistan Medical Association.
Price: Rs. 150.00, Annual subscription: Rs.1,500.00 in Pakistan and US$100.00 for overseas countries.
Publication Office: PMA House, Aga Khan III Road, Karachi-74400, Pakistan.
Telephone/Fax: 9221-2226443 Email: jpma_jpma@hotmail.com, editor@jpma.org.pk
Editorial
HIV/AIDS in Pakistan: Has the explosion begun?
Sten H. Vermund1, Heather White2, Sharaf Ali Shah3, Arshad Altaf4, Sibylle Kristensen5, Rafique Khanani6, Syed Abdul Mujeeb7
Vanderbilt University School of Medicine, Vanderbilt University Institute of Global Health, Nashville1, USA, University of Alabama at Birmingham
School of Public Health2, Dow University of Health Sciences3, Karachi, Pakistan, Canada-Pakistan HIV/AIDS Surveillance Project4, Islamabad, Pakistan,
University of Alabama at Birmingham5, USA, Dow University of Health Sciences6, Karachi, Pakistan, AIDS Surveillance Centre7, Jinnah Postgraduate
Medical Centre, Karachi, Pakistan.
This special issue of the Journal of the Pakistan Medical is likely to exacerbate already poor health conditions for
Association (JPMA) seeks to bring vital HIV/AIDS Pakistanis; HIV may well affect Pakistan's military and
information from the global literature into the hands of middle class as well.13 The potential for destabilization of
Pakistani physicians, scientists, nurses and policy makers. social and political structures is worrisome.14-16
Even as the attention of the world is focused on the terrible
aftermath of the catastrophic earthquake in northern The importance of surveillance and related research in
Pakistan in October 2005, we believe that the timing of this combating the epidemic is highlighted throughout these papers,
issue is nonetheless most opportune. including the value of behavioral surveillence. Cross-section
surveys and sentinel surveillance strategies can help the
Recent changes in the epidemiologic data regarding HIV authorities track the epidemic in cost-effective ways;17 data can
prevalence in Pakistan suggest alarm. Unpublished data then be used to alert the local citizenry as well as provincial,
indicate a recent upsurge in HIV prevalence from surveys of national and international agencies. Surveillance, prevention
injection drug users (IDUs) all around the nation. Sindh and access to care will depend on a much improved voluntary
AIDS Control Program data suggest IDUs in Karachi to counseling and testing (VCT) infrastructure;18 insufficient
have a 9% HIV seroprevalence rate (Sharaf Ali Shah, investments have been made to date.
personal communication). Family Health International1 -
sponsored cross-sectional studies in 2002-2003 suggest Some of the articles in this special issue highlight the
23% seroprevalence among IDUs in Karachi; HIV/AIDS importance of blood safety. Many blood transfusions and
Surveillance Project (HASP) of Canadian International injections in Pakistan are not indicated medically, since iron
Development Agency results in 2004 suggested 26% supplementation or oral medicines would do just as well.
seroprevalence among IDUs in Karachi (Arshad Altaf, The urgent need for Pakistani legislation to regulate and
personal communication). HIV is now documented enforce regulation of blood banks is highlighted.19,20 The
routinely among IDUs in other cities of the country, need for excellent HIV tests suitable for mass use is
including Rawalpindi, Lahore and Sargodha.2 There is no emphasized.21 Issues of risk from handling contaminated
question that Pakistan has moved from a nascent epidemic needles are emphasized.22 Rural areas of Pakistan have some
into one with a concentrated epidemic, with high prevalence of the world's highest hepatitis C rates due, presumably, to
in at least one major high risk population. contaminated reuse of needles for medical purposes.23 Few
Pakistanis are aware of the risks of transfusions.24 Another
The papers in this issue sound the alarm vis-à-vis the thoughtful paper highlights the existence of low
circumstances in Pakistan that are likely to nurture HIV, seroprevalence subgroups of young adults for hepatitis B
including inadequate screening, public awareness and virus, hepatitis C virus and HIV, suggesting the need to
prevention services, including control of sexually transmitted recruit such persons as regular voluntary blood donors.25
infections(STIs).3-6 High risk populations such as commercial
sex workers, hijras and other men who have sex with men, While high risk populations in Pakistan (e.g., IDUs, truck
long-distance truckers, sailors, needle sharers, prisoners and drivers, hijras, prisoners, sailors, commercial sex workers)
recipients of unscreened blood products from paid donors are would seem to be highly disparate, they do share many
all prevalent in Pakistan.7-11 Infection is introduced regularly features, including low rates of condom use and multiple
from Pakistani men who work abroad, especially in the Gulf partners, coupled with poor knowledge of HIV transmission
states and are sent home after HIV is diagnosed.12 The health and methods for prevention.26-30 The need for targeted
and socioeconomic impact of a major HIV/AIDS in Pakistan programs of education and rehabilitation is made clear by
Correspondence: Sten H. Vermund, Vanderbilt University Institute for Global Health, Room 319, Light Hall, Nashville, TN 37232-0242, Email:
sten.vermund@vanderbilt.edu
Supported in part by training grant 7D43 TW01035-07 from the Fogarty International Center, National Institutes of Health (USA). Dr. Vermund is Professor
of Pediatrics, Amos Christie, Professor of Global Health and Director of VUSM's Institute for Global Health.
Risk group category Paid blood donor Drug addict Wife of case #2 Son of case #2
Age 33 yrs. 34 yrs. 29 yrs. 13 months
Date of serum 12-27-85 2-2-86 5-20-86 7-7-86
collection
Marital status Married Married Married ---
Blood Transfusion Once, 10 yrs. ago None None None
Hepatitis 4-5 yrs. ago N/A N/A N/A
(Jaundice) (1981-1982)
Sexual contacts Promiscuous Promiscuous Monogamous ---
heterosexual bisexual
Drug abuse By inhalation or Primarily inhalation; --- ---
parenterally occasionally
parenterally
Travel abroad Never Never Never Never
Clinical exam. Persistent Persistent Not significant Developmental
lymphadenopathy lymphadenopathy disorders
(Delayed
milestones)
Neurologic
manifestations
HIV antibodies Reactive Reactive Reactive Reactive
(both ELISA and
Immunoblot)
HIV-antigen (p 24) Reactive Reactive Reactive Reactive
Results female was the wife of the seropositive drug addict and the
Four of the 230 sera tested repeatedly reacted by the HIV- child was the last one of the five children born to this couple
antibody EL1SA and immunoblot assays indicating (Table 1).
seropositivity of four individuals (Tables 1, 2 and Figure).
Sera from these four cases were also reactive for HlV-p24 Although 14 of 121 sera from blood donors initially reacted
in the HIV-antibody test (Abbott EIA, Pakistan), three sera
antigen, suggesting active viral infection in all four
reacted in repeated EIA (Abbott, Pakistan) and only one
seropositive individuals. Attempts are now under way to
serum reacted by the Organon Teknika ELISA (Table 2 and
isolate virus from these individuals In vitro. Of the four
Figure). Sera from 25 recipients of multiple blood
confirmed cases, two were males, one female and one child.
transfusions, 24 cases with persistent lymphadenopathy, 39
One male was a blood donor and one a drug addict. The
Total 230 20 6 4 4
(8.7) (2.6) (1.7) (1.7)
Figure. Test sera were reacted with the immobilized HIV proteins and reactive antibodies were visualized by Biotin-labeled anti-human IgG followed by Sreptavidin-horseradish peroxidase conjugate and
development of color reactionby a chromogen. Distinct bands reactive with specific HIV antigens were identified and the banding pattern was compared with that obtained by reaction with HIV-positive and
HIV negative standard sera:11 +.=HIV antibody positive control; a = blood donor: b = drug addict: c = wile; d = child: and - = negative control. Molecular weights of HIV proteins are indicated on the left-
hand side.
Total: 51 36
Sub-group 2 - Frequent travel abroad The cases in which indeterminate results were obtained on
Included in this category were 3 individuals whose job WB those patients were requested to submit samples again
involved very frequent visits to various parts of the world. at three and six months interval. Unfortunately these few
individuals in our case were lost to follow-up.
Sub-group 3 - Recipients of multiple transfusions
The individuals of this group included a haemophiliac and a
patient with thalassemia major. The third individual
Discussion
apparently had undergone cardiac bypass surgery in London In Pakistan, according to the official statistics, more than
in 1982, when screening of blood products for HIV 250,000 individuals have been screened for HIV-I infection
infection was non-existent. Similarly, the above patient of and a total of 129 cases of sero-positivity have been
thalassemia had been receiving transfusions in the Middle detected so far. Nineteen individuals developed AIDS, out
East, where most of the blood till 1985 was imported from of them 17 have died and two are still alive.10 A
abroad. The screening of blood products came into full play conservative estimate by WHO indicates over 1 million
in 1985, in USA. infections in South and South-East Asia, the vast majority
of them in India and Thailand.
Sub-group 4 - Family members/close contacts
At the moment, two cases of HIV transmission to spouses Abdul Mujeeb et al. reported that during 1986-87, 1,363
are present in our record, heterosexual transmission being subjects were screened for HIV infection in Karachi, 2 were
the most probable causes. confirmed positive by WB.5 These two were married
females who had received multiple transfusions and denied
Sub-group 5 - Vertical Transmission other risk factors. Khanani et al reported another 3
There is so far only one possible case of this pattern in our confirmed cases of HIV infection in a group of 413 screened
observation, where the mother had possibly acquired the individuals from Karachi in 1990.6 Two were foreign
infection in a Middle East country after receiving multiple nationals of Tanzania and Uganda and third individual was
The largest group of positive patients is represented by It is stated that the presence of a pre-existing sexually
foreigners/ expatriates, individuals with frequent travel transmitted disease increases the risk of HIV transmission
history and recipients of multiple transfusions. The common by sexual intercourse. The most common means of HIV
denominator in all these cases is the fact that HIV infection transmission is now heterosexual contact and if left
was acquired outside Pakistan by different modes during unchecked will continue to be the main means of spread in
their long or short stay abroad. Some of the confirmed cases Asia. India and Thailand with their rapidly increasing
further transmitted it to their spouses. One of the donor number of AIDS patients have well supported these facts.
sample confirmed for HIV infection belonged to an The adult population in South and South East Asia is 500
individual living outside Pakistan in UAE for the last 10-12 million as compared with 225 million in sub-Saharan
years. All our positive cases depict the classical modes of Africa, therefore, the pandemic may grow at a much faster
transmission of HIV-I virus.11 The data also shows an rate in our part of the world. In developing countries of
increase in the number of HIV-I positivity. In the first year Africa, Asia and Latin America, the ratio of infection in
June 1986-June 1987, 5 individuals were positive for HIV- men and women is almost equal or rapidly becoming so,
I infection whereas in the last year, July 1991-June 1992, indicating the predominance of heterosexual transmission.
twelve cases of HIV-I positivity were demonstrated. Most WHO estimates that nearly one half of new adult infections
of the positive individuals fell into the 20-50 years age have occurred among women. Recent estimates have
group. indicated that 2.1-6.7 million Thais will be infected by year
2000.
Asia was labelled as having no specific mode of
transmission of HIV-I virus in a study conducted in 1988 by It is presently estimated that India has 2.7 million HIV
WHO, whereas patterns I and II were assigned to USA, positive cases. In a study conducted in India to determine
Western Europe and sub-Saharan Africa respectively.12 the incidence of HIV infection in hemophiliac patients and
Heterosexual transmission was declared as the dominant those receiving multiple transfusions, 16 out of 124
mode of spread in Africa and homosexual and intravenous individuals were positive for HIV infection.15 In another
drug abusers were involved in spread of disease in the study from India, 182 vials of commercially available blood
western countries including USA. The epidemiological products revealed 32 products to be positive for HIV
picture has now changed. On March 1, 1989, 141,894 AIDS antibodies. These products are prepared from blood
cases were reported to WHO Global programme on AIDS collected from professional donors.16 It is of utmost
from 145 countries. 70% of the world total cases were from importance to prevent transmission through blood products
America, 85% of these from USA13, but presently, the sub- in our country.
Saharan Africa has the largest number of HIV infected
individuals and it is projected that by year 2000, Asia will In Pakistan, practice of screening of blood products for HIV
account for 42% of HIV infections.2 90% of those with infection is practically absent. Only a few large medical
AIDS in developing countries and industrial countries are centres in the country are screening blood products. The
between the ages of 20-49.4 The present regional risks in the Western countries have been minimized by
distribution of cumulative adult HIV infections based on screening all donated blood and heat treatment of blood
WHO statistics indicates that sub-Saharan Africa has over 7 factors VIII and IX. In the United States where every blood
million infections; North America and Latin America, unit is screened, the statistical incidence of transfusion
including the Caribbean, have over 2 million; South and associated AIDS is estimated to be 1 in 1,25,000 blood
South East Asia have over 1 million, followed by Europe, donations.17 The risk of acquiring HIV infection through
North Africa, Midddle East, Australia, East Asia and transfusion is approximately 1 in 153,000 per component.18
enforced by governmental agencies in Pakistan to limit the 2. World AIDS cases. Quarterly update, World Health Organization global
Programme on AIDS, July 1992.
progress of this disease. Similarly, use of blood from 3. Pakistan drug information, Ministry of Health Special Education and Social
professional donors needs to be eliminated. Welfare, Government of Pakistan, Islamabad. Jan 1992, (3) p 27.
4. Kerr DL. HIV infection and AIDS in Africa and the third World. AIDS
Our data depicts the number of HIV-I positive individuals update. J Sch Health 1989;59:369-70.
5. Mujeeb SA, Hashmi MRA. A study of HIV antibody in sera of blood donors
in a cross-section of our population. As the samples were and people at risk J Pak Med Assoc 1988;38-221-22.
collected from individuals residing temporarily or 6. Khanani RM, Hafeez A, Rab SM, Rasheed S. AIDS and HIV associated
permanently in Karachi at the time of sample collection one disorders in Karachi J Pak Med Assoc 1990;40:82-5.
may speculate that the results are of collection of pattern 7. Dodd RY, Fang CT. The western immunoblot procedure for HIV antibodies
and its interpretation. Arch Pathol Lab Med 1990;114:240-45.
not only in Karachi but of the country as well. Further
8. Tribe DE, Reed DL, Lindell P. et al. Antibodies reactive with human
studies to determine the prevalence in high risk groups is immunodeficiency virus gag-coded antigens (gap reactive only) are a major
essential. A recent study19 elicited that more than 33,000 cause of enzyme-linked immunosorbent assay reactivity in a blood donor
population. J Clin Microbiol 1988;26:641-47.
samples were tested out of which fifteen were confirmed to
9. Stevens RW, McQuillan GM. Sero diagnosis of human immunodeficiency
carry HIV-I infection by WB. These cases represented virus (HIV) and hepatitis B virus (HBV) infections in clinical diagnosis and
external source, i.e., outside Pakistan as a cause. It is also management by laboratory methods Henry J, Bernard, 18th ed, Philadelphia:
stated that a definite increase in the number of positive cases W. B. Saunders, 1999, pp. 912-18.
10. Report of the National AIDS Seminar, National AIDS prevention and control
is seen after 1990. The official number of known cases of programme for Pakistan Ministry of Health, Government of Pakistan, June
sero-positivity in Pakistan is presently only 129 as of June 1992.
1992. Nevertheless, proper health education has to be 11. Friedland GH, Klein RS. Transmission of the human immunodeficiency virus.
delivered to the public. It is strongly recommended that the New Engl J Med 1987:317:1125-35.
12. Kreiss JK, Castro KG., Special considerations for managing suspected human
news media, radio, television, social workers, health care immunodeficiency virus infection and AIDS in patients from developing
workers and politicians should create public awareness. countries. J. Infect. Dis., 1990;162:955-59.
Methods of preventing the spread should be publicized. 13. Notes and News. AIDS in the UK and worldwide. Lancet 1989;1:914-15.
Sero-surveillance of selected segments of population to 14. Hale J. The third world: AIDS finds a comfortable home. Can Med Assoc J
1990;142:869-70.
assess the current AIDS situation and to monitor
15. Singh YN, Bhargav M, Malaviya AN. et al. HIV infection in Asian India
progression of HIV should be carried out. Despite the patients with hemophilia and those who had multiple transfusions, Indian J
limitations and shortcomings of our study, we strongly feel Med Res 1991;93:12-14.
that there is an increase in HIV-I infection in Pakistan and 16. Tripathy SP, Malariya AN, Singh YN, et al. HIV antibody screening of
commercially available blood products in India. Indian J Med Res
there is no proven indigenous case of AIDS in our series. 1991;93:15-18.
High risk behaviour groups should be screened to assess the 17. Bove JR. Transfusion associated hepatitis and AIDS. What is the risk? N Eng
true prevalence of this infection. J Med 1987;317:242-45.
18. Monitore JE. Current risk of transfusion associated human immunodeficiency
virus infection. Arch Pathol Lab Med 1990;114:330-34.
References 19. Waheed-Uz-Zaman. Spread of HIV infection in Northern Pakistan (abstract).
1. Hayward WL, Curran .W. The epidemiology of AIDS in the US. In the Proceedings of 3rd International Conference of Pakistan Association of
science of AIDS, readings from scientific America. Freeman and Co., New Pathologists, Lahore, Pakistan. Nov. 1991 pp. 22-25.
probably will effectively start functioning from next 13. Mujeeb SA, Kayani N, Khursheed M. HIV/AIDS in Pakistan care caring
1999;7:31.
financial year 1995-96. 14. Mujeeb SA Khanani RM, Khursheed T, et, al, Prevalence of HIV infection
among blood donors. J Pak Med Assoc 1991:41:253-54.
The effectiveness of the National AIDS Programme in 15. Friedland GII. Klein RS. Transmission of the Human Immunodeficiency
Virus. N Engl J Med 1987:317:1125-35.
curbing the incidence of HIV/AIDS and raising preventive 16. Quinn TC, Mann JM, Curran JW, et al. AIDS in Africa: an epidemiologic
awareness cannot, at this stage, be properly evaluated. paradigm. Science 1986:234:955-63.
Pakistan has a population of approximately 140 million In Lahore, among 2000 pregnant women studied, 12 (0.2%)
with an annual population growth rate of 2.8%. In 1995, the were HIV antibody positive. In Karachi among 2020
gross domestic product per capita was US$470. The urban pregnant women tested, none were found to be HIV
population is 33.3%. There is a low literacy rate among the positive. Out of 900 and 295 pregnant women in Faisalabad
general public with insufficient awareness regarding and Mirpur, respectively, none were found to be HIV
HIV/AIDS transmission. About 4 million nationals are positive.
working abroad with their families based in Pakistan. Table. HIV seroprevalence surveillance, Paksitan.
By October 1995, Pakistan had reported 52 AIDS cases to Centre town Population Sample 95%
the World Health Organization (WHO) and 969 persons
A Lahore Antenatal 2000 0.6 <1.0
have been identified as HIV-infected. In 1987, the National attenders
AIDS Programme (NAP) established a national AIDS and B Karachi Antenatal 2020 0 -
HIV surveillance system. In 1995, in accordance with WHO attenders
guidelines, NAP embarked on conducting HIV C Mirpur Antenatal 259 0 -
attenders
Seroprevalence surveys to determine the extent of the D Faisalabad Antenatal 900 0 -
epidemic as well as to establish indexes of the effectiveness attenders
of prevention activities.1-3 Here we present the results of E Lahore STD clinic 295 3.7 3.5-3.9
cross-sectional surveys of several population groups attenders
F Karachi STD clinic 402 0.2 <1.0
performed between July and November 1995. attenders
G Peshawar OPD clinic 237 3.7 3.5-3.9
Pregnant women were tested for HIV at their first prenatal attenders
examination. Four obstetrical clinics participated, one in H Quetta Tuberculosis 210 2.8 2.4-3.2
Patients
Lahore (centre A), one in Karachi (centre B), one in Mirpur I Lahore Drug users 313 11.5 10.9-12.1
(center c) and other one in Faisalabad (centre D). Patients J Karachi Truck drivers 225 0 -
attending sexually transmitted disease (STD) clinics who
are systematically screened for syphilis were also OPD = outpatient department
During the study period, a total of 6861 persons were To decrease selection and participation bias, it was
enrolled and analysed (Table). originally planned to use only unliked anonymous testing.
Summary the country: 45% of all AIDS cases and 32% of all HIV-
HIV prevalence is still very low in Pakistan, but its south positive cases (without AIDS).3,4 The capital of Sindh is
Asian location and subgroups with recognized lifestyle Karachi, which in addition to being the most urbanized city
risk factors suggest that Pakistan will experience in the country, is the only major commercial seaport in
expanded diffusion of HIV. We report the frequency of Pakistan. Its population is 10 million and it hosts 70% of the
HIV infections identified by the AIDS Control country's factory based industry.
Programme in the Sindh province of Pakistan. Most
HIV positive cases currently reported to the Sindh AIDS A large number of Pakistani citizens are employed in the
Control Programme are found among Pakistani Gulf States (e.g. Saudi Arabia, Kuwait, United Arab
workers deported from the Gulf States and among Emirates). In Saudi Arabia, 27% of the population are
foreigners. The 58 returned workers with HIV represent foreign nationals who make up over half of the work force.5
61 to 86% of reported cases in any given year during the Before being granted a resident permit, foreign nationals
1996-1998 period. Five wives of returning workers have entering the Gulf States are tested for HIV in their country
been identified with HIV. Expatriate workers in the of origin. Resident permits are not granted to HIV positive
Gulf States are tested for HIV routinely, unlike other individuals.5 Foreign nationals are required to renew their
subgroups in Pakistan. Considering the risk of work permit and their HIV test every 2 years. Anyone found
HIV/AIDS due to regular introduction of HIV from HIV positive is deported immediately to his country of
returned workers, and the limited awareness origin. Treatment or counselling is rarely provided.5,6
surrounding sexual health and HIV/STD transmission
issues in Pakistan, intervention programmes targeted at Methods
overseas workers need to be implemented to control the The data collected for this paper originated from 10 HIV
expansion of the HIV epidemic in Pakistan (Int J STD surveillance centres established in 1995 by the Sindh AIDS
AIDS 1999;10:812-14). Control Programme. HIVtesting in Pakistan is done largely
on a voluntary basis. The Sindh AIDS control programme
Keywords: HIV, acquired immunodeficiency syndrome, has established an outreach programme towards public and
migration, Pakistan, surveillance, Middle East. private health-care practitioners to enhance the practice of
HIV testing among their high-risk and/or symptomatic
Introduction patients. HIV infected deported workers are reported to the
The first case of AIDS was confirmed in Pakistan in 1987.1 AIDS control programme by the Pakistani immigration
While the prevalence of HIV is still low in Pakistan, its services but most deported workers report on their own to
geographic proximity to India, a country experiencing a an HTV surveillance centre for diagnosis confirmation. The
severe HIV/AIDS epidemic, and several prevalent lifestyle 10 Sindh HIV surveillance centers offer free HIV testing,
risk factors make Pakistan a high-risk location for diffusion condoms, and pre- and post-test counselling. An enzyme-
of HIV.2 HIV risk factors in Pakistan include internal and linked immunosorbent assay (ELISA) for HIV (Abbott
external migration, commercial sex work, failure to use Park) is performed at the central laboratory of the Sindh
condoms, male to male sex and re-use of contaminated AIDS Control Programme in Karachi. The Sindh AIDS
needles, particularly in the informal health-care sector.2,3 Control Programme follows the World Health Organization
Judging from surveillance data, sex is the predominant (WHO) recommendation for cost-efficient HIV testing. A
mode of transmission and most reported HIV cases to date positive ELISA test is confirmed positive with a second
are among men.3 positive ELISA (Behring) and a positive agglutination test
(Serodia, Fujirebio kit). HIV-positive patients are referred
Sindh is the second most populated province of Pakistan to the Dow Medical College for medical evaluation and
with 35 million persons (25% of the population of treatment of opportunistic infections (mainly tuberculosis).
Pakistan). Sindh has the highest number of reported cases in Due to their high price and difficulties in treatment
Table. H1V/AIDS cases investigated by the Sindh AIDS Control Programme, 1996-1998.
References 15. Hyder AA, Khan OA. HIV/AlDS in Pakistan: the context and magnitude of
an emerging threat. J Epidemiol Comm Health 1998; 52:579-85.
1. Khanani RM, Hafeez A, Rab SM, Rasheed S. Human immunodeficiency 16. Khan OA. The role of information, education and communication (IEC) in
virus-associated disorders in Pakistan AIDS Res Hum Retroviruses HIV/AlDS prevention and control in Pakistan. WHO/EMR AIDS News 1998;
1988;4:149-54. 2:4-6.
HCV positive on Abbott Diagnostic System. None of the 2. Mujeeb SA. Seroprevelence and pattern of viral hepatitis in Pakistan. J Infect
Dis 1998;5:19-20.
donors were HIV positive on anti HIVI, 2 Abbott 3. Mujeeb SA. Prevalence of hepatitis B,C and HIV infection among family
Diagnostic kit. blood donor population. Ann Saudi Med 1996;16:702-703.
Background: National legislation in Pakistan regulating facilities and equipment, and observed blood collection
blood banks has been introduced several times, but has using structured questionnaires and observation forms.
never been passed. To support provincial-level efforts to Results: Of the 37 selected facilities, 25 were operational
develop legislation we conducted a study to evaluate blood- and 24 agreed to participate. Twelve (50%) of the facilities
banking practices in Karachi, Pakistan, to identify areas that reported regularly utilizing paid blood donors, while only
could be improved. six (25%) actively recruited volunteer donors. During
Methods: Thirty-seven blood banks were randomly observation only 8% of facilities asked donors about
selected from a list of 87 Karachi blood banks. The research injecting drug use, and none asked donors any questions
team interviewed blood bank personnel, inspected available about high-risk sexual behaviour. While 95% of blood banks
Figure.
Deferral criteria No. (%) of blood banks reporting No. (%) of blood banks observed to be
to use this criteria (n = 21) asking donors these questions (n = 12)
Physical examination No. (%) reporting using No. (%) observed to evaluate
these criteria (n = 21) these criteria (n = 12)
Laboratory blood screening No. reported screening / No. (%) observed with equipment
No. asked (%) and reagents (n = 22)
equipment and reagents to screen for hepatitis B, 55% for Table 2. Blood transfusion setting Karachi 1995.
HIV and 23% for hepatitis C (Table 1). On observation, two
of the facilities were pooling specimens prior to testing Number (%)a
them for HIV and two were pooling specimens to screen for
hepatitis C. Although not a part of the structured Facility typeb
questionnaire, respondents at 25% of the facilities Private Hospitals 442 (49)
spontaneously reported that even when they had equipment Government hospitals 292 (33)
Maternity homes 96 (11)
and reagents, they did not screen every unit of blood for General practitioner clinics 8 (1)
infectious agents, but did so selectively. This selection was Other 60 (7)
usually dependent upon the recipient's willingness to pay Hospital wardc
for the costs of the screening tests. Obstetrics and gynecology 86 (44)
Surgery 47 (24)
Emergency 24 (12)
Whole blood was dispensed from all of the facilities, packed Haematology/ Oncology 5 (3)
cells from 16 (70%). fresh frozen plasma from 10 (43%), Other wards 32 (16)
platelets from 7 (30%), and cryoprecipitates from 5 (22%). a Percentages do not add up to 100% because of rounding.
Six of the blood banks (26%) offered only whole blood. b Includes data from the last 50 donations from the 21 facilities that permitted
the study team to review their records (n = 898).
Eighty-three percent of blood banks (15/18), including 63% c Includes those 194 transfusions that took place in hospitals where the ward was
noted in the register.
(10/16) of the blood banks dispensing components,
collected their blood products in a single bag, rather than facilities in Karachi in the week prior to the study team's
into multiple bags to ensure aseptic separation of blood visit (range 2-490). Sixty-five percent of blood banks
products as recommended by WHO.12 All of the facilities distributed fewer than 20 units of blood in the week
had a refrigerator. At the time of inspection the temperature preceding the study visit. The observed weekly rate
of the refrigerators was outside the WHO recommended extrapolates to 2950 units of blood transfused in an average
limits in 29% of the facilities (Figure). week or 153 400 units in a year in Karachi. Most of the
blood was transfused in hospitals, with obstetric and
On average 50 units were dispensed from each of the surgical units being the most common users (Table 2).
an objective assessment of compliance and quality 12. Gibbs WN, Britten AFH (eds). Guidelines for organization of blood
Transfusion service. Geneva: World Health Organization 1992.
assurance will be required. 13. Statistical Supplement. Economic Survey 1995-96. Government of Pakistan,
Finance Division. Economic Advisor Wing. Islamabad, 1997.
There are clear economic barriers to safe transfusion 14. Ahmed A. Shamsi TS, Hafiz S, Hashmi KZ. Zafar MN, Syed S. Seroprevalence
of Hepatitis B and C Virus among Professional Blood Donors-A Single Centre
practices in developing countries. Screening and storing Study of 135 Donors in Karachi. J Pak Med Assoc 1995;45:309.
blood safely requires trained personnel and expensive 15. Kakepoto GN, Bhally HS, Khaliq G. Epidemiology of blood- borne viruses:
equipment and consumables. In the unregulated market for A study of healthy blood donors in Southern Pakistan. . South East Asian J
Trop Med and Public Health 19966;27:703-6.
blood in Karachi, financial considerations, for example the
16. The Sindh Government Gazette. Karachi: Sindh Government, August 2S,
recipient's willingness to pay for blood screening for 1996. pp. 86 -90.
infectious pathogens, were a central determinant of
transfusion safety. And Karachi, where we found marked Acknowledgements
limitations in equipment and supplies, is the economic hub This project was supported by the Department of
of the country. Sixty-six percent of Pakistan's population Community Health Sciences. The Aga Khan University.
lives in rural areas9 where there is no immediate access to Karachi. Pakistan.
blood transfusion services. Thus, to bring quality blood
transfusion services throughout underdeveloped countries
requires economic growth. This lack of optimal resources, Biographies
Stephen Luby, MD, studied internal medicine at Strong Memorial
however, should not limit public health advocates or Hospital, Rochester. NY, USA, and epidemiology at the United
developing country legislators from demanding States Centers for Disease Control. He directed the epidemiology.
accountability and efficient use of available transfusion unit of the Department of Community Health Sciences, Aga Khan
resources. This study, for example, suggests that elimination University. Karachi from 1993 to 1998. He is currently conducting
research on diarrhoeal prevention in developing countries with the
of paid blood donors would be a particularly efficient way Centers for Disease Control.
to improve the safely of the blood supply. Although this
requires an aggressive public health effort, and a change in Rafique Khanani, MBBS, is an assistant professor of pathology at.
attitudes and orientation, it does not require substantial Sindh Medical College. He is, Secretary General of Infection
Control Society. Pakistan.
capital or technology. Moreover, this basic approach of
collecting representative data of current practices may be a Maliha Zia, M.B.B.S. is a graduate of the Aga Khan University.
useful first step towards improving blood safety in other She is currently working as a surgical house officer in Lahore.
developing countries.
Zuleikha Vellani, MBBS, is a graduate of the Aga Khan University,
and has completed a one-year internship at the same institution. She
References is pursuing an academic career in Family Medicine.
1. Demaeyer E, Adiels -Tegman M. The prevalence of anemia in the world.
Health Statistics Quarterly 1985:38: 302-16.
Mohsin Ali, MBBS, is a graduate of the Aga Khan University. He
is currently an internal medicine resident at Syracuse University.
2. World Health Organization. The World Health Report 1995 Bridging the gaps.
Geneva: World Health Organization, 1995.
3. Greenberg AE, Nguyen-Dinh P. Mann JM et al. The association between
Abdul Haleem Qureshi, MBBS, is a graduate of the Aga Khan
malaria, blood transfusions, and HIV seropositivity in a pediatric population University. He is currently a surgical resident at the Aga Khan
in Kinshasa, Zaire. J Am Med Assoc I988; 259(4):545-9. University Hospital.
Objectives: To determine the knowledge, attitudes and counseling regarding further prevention. This study was
practices regarding diagnosis and treatment of sexually conducted to assess the knowledge, attitude and practices
transmitted infections (STIs) among specialists that is, regarding STIs among general practitioners (GPs) and
dermatologist, gynecologists and urologists and general specialists in Karachi, Pakistan.
practitioners (GPs) in Karachi, Pakistan.
Methods: Interviewers administered structured Methods
questionnaires to doctors conducting outpatient clinics at
tertiary hospitals and/or private clinics in Karachi. All Study Population and Sampling Methods
private clinics within a 10 km radius of the Aga Khan We selected hospitals in Karachi that had more than 100
University and all tertiary hospitals having more than 100 inpatient beds and a separate outpatient department. We
inpatient beds were included in the study. approached all the gynecologists, urologists and
Results: One hundred doctors (54 specialists and 46 GPs) dermatologists practicing at these facilities. A
responded. Eighty doctors reported seeing at least one STI pharmaceutical company, which marketed products used for
patient/month. The most commonly diagnosed STI the STI treatment, provided us with a list of the gynecologists,
doctors reported was urethritis/cervicitis syndrome. 50% of urologists, dermatologists and general practitioners (GPs)
the doctors knew the recommended antibiotics for whose work addresses were within 10 km of the Aga Khan
gonorrhea though only 46% of these knew the correct University. We approached each of these practitioners.
dosage. Specialists were three times more likely to
recognize the clinical presentation of herpes and twice as We classified doctors as specialists if they had received
likely to treat chlamydia, syphilis and herpes with postgraduate training in their respective specialties and GPs
appropriate antimicrobials than GPs. 85% of the doctors were licensed doctors who had not received any formal
advised their STI patients regarding condom usage; 36% postgraduate training.
thought that STI patients had loose sexual morals, 43%
believed STI patients were drug addicts. Over 90% of the Materials
physicians were willing to attend educational sessions and Interviewers administered a 39 item structured
follow a national STI treatment protocol. questionnaire.
Conclusion: Doctors in Karachi, especially GPs, are
deficient in appropriately managing and counseling STI Statistical Method and Analysis
patients. Among the specialists, urologists and We classified doctors as seeing and treating STI patients if
dermatologists were more likely to manage STIs correctly he/she saw at least one STI patient per month.
than gynecologists. Karachi doctors should be educated in
the correct management and counseling of STIs to prevent Treatment responses (drug choice and dose/duration of
further spread of STIs including AIDS (Sex Transm Inf administration) were considered correct if they coincided
2000;76:383-85). with the current WHO or US Centers for Disease Control
and Prevention (CDC) criteria for the treatment of STIs.3,4
Introduction
We compared the difference between groups using relative
Pakistan is thought to have a low prevalence but a high risk
of HIV.1 Sexually transmitted infections (STIs) increase the risks and evaluated the potential of chance using X2. We
considered a p value of <0.05 as statistically significant. All
risk of HIV transmission twofold to sixfold.2 Thus control
and prevention of STIs is an important strategy for analysis was carried out using EPI-INFO.5
preventing HIV.
Results
Physicians have a vital role in interrupting the spread of We approached 120 doctors; 100 (83%) completed the
STIs through early diagnosis, appropriate treatment and questionnaire including 46 GPs, 23 dermatologists, 21
Appropriate dose and duration 15 (54) 8 (36) 1.5 0.8, 2.8 0.226
of antimicrobials for gonorrhea
Treatment of both gonorrhea and 28 (54) 14 (33) 1.7 1.0, 2.7 0.038
Chlamydia for mucopus in cervix/
urethra
Appropriate dose and duration 22 (56) 6 (32) 1.8 0.9, 3.7 0.076
of antimicrobials for chlamydia
Appropriate dose and duration 22 (51) 2 (9) 5.6 1.5, 21.8 0.001
of antimicrobials for syphilis
Diagnosis of painful genital vesicular 38 (72) 13 (28) 2.5 1.6, 4.1 0.000
lesions as herpes genitalis
Appropriate dose and duration of 15 (43) 5 (63) 0.7 0.4, 1.3 0.315
antimicrobials for herpes genitalis
*In accordance with international guidelines. Percentages are out of the total responses received.
gynecologists and 10 urologists. gonorrhea only, 10 (10%) would treat for chlamydia only,
while five (5%) would treat for syphilis. Specialists were
Of the 100 interviewed doctors, 80 had seen at least one consistent more likely to answer questions in accordance
new STI patient in the preceding month. The mean number with international guidelines for diagnosis and treatment of
of STI patients seen per month by specialty were STIs than were general practitioners. However, even among
dermatologists 15, gynecologists 13, urologists 6 and GPs 4
specialists, less than half were able to correctly state the
patients.
dose and duration of antimicrobial treatment for the most
When asked, using an open ended question, what the most common STIs (Table). Among specialists, compared with
common STI they saw in their practice, 53% of gynecologists, urologists and dermatologists were 2.5 times
gynecologists responded vaginal candidiasis, a syndrome more likely to report the appropriate dose and duration of
that is not even an STI. The other physicians reported penicillin for syphilis (61% versus 25%, relative-risk 2.5,
gonorrhea as most common. p=0.03) and 1.9 times more likely to report the appropriate
antimicrobials for treatment of gonorrhea (64% versus 33%,
Knowledge
relative risk 1.9, p=0.03).
We asked all the doctors questions regarding knowledge of
STIs. Given a patient presenting with mucopus in the The doctors listed their major sources of knowledge
cervix/urethra, 42 (44%) said that they would treat for both, regarding STIs as medical training (52%), medical journals
gonorrhea and chlamydia, 38 (40%) would treat for (50%) and continuous medical education 30%).
Thirty six percent of the doctors believed that STI patients We are grateful to Naeem Rahim, Amana Nasir, Sumbal
had loose morals; 21% believed that STI patients could not Khalid, Khalid Nur, Aida Khanum and Shakeel Thakurdas
give up their careless sexual behavior; while 43% believed for their contribution in data collection. The project was
that STI patients had other bad habits like drug addictions. funded by the Department of Community Health Sciences,
the Aga Khan University, Karachi.
When asked what the single most important factor in the
control of AIDS in Pakistan was, 81% answered mass media Contributor
(radio, television and newspapers) while 13% thought that HEK was the primary author of the study protocol, assistant
education by doctors was the most effective way. in development of the questionnaires and drafted the
manuscript, SL reviewed each draft of the protocol,
Ninety two per cent of the doctors were interested in questionnaire and manuscript, framed the analysis and
attending continuing medical education seminars on STI outlined the manuscript; SR assisted in the development of
control and 95% reported being willing to follow a the protocol and questionnaire, supervised the field work
standardized protocol for the management and counseling and reviewed the manuscript.
of STI patients.
References
Discussion 1. Laqa M. Epidemiology and control of STDs in developing countries. Sex
Karachi physicians, both GPs and specialists, lacked Transm Dis 1994;21 (Suppl).
sufficient knowledge of STI symptomatology and therapy 2. Laga M, Diallo MO, Bune A. Inter-relationship of STD and HIV/AIDS 1994,
a year in review.
to diagnose and treat STI patients appropriately. When
3. Centers for Disease Control and Prevention sexually transmitted disease guide
presented with hypothetical cases of common STIs syphilis, 1993. Atlanta CDC.
chlamydia and gonorrhea - the majority of cases were 4. Drugs used in STDs and HIV infection. WHO model prescribing information.
incorrectly diagnosed and the drug dose and duration for the Geneva: WHO, 1995.
STIs questioned was, more than half the time, inappropriate. 5. Dean AG, Dean JA, Coulombier D, et al. Epi Info, Versions 6.04. Atlanta,
GA: Centers for disease Control and Prevention, USA, 1995.
Compared to the GPs, specialists were more likely to 6. Gully PR, Fisher DC, Pless R, et al. How well do family physicians manage
diagnose STDs correctly and to prescribe the appropriate sexually transmitted disease. Fam Physician 1995;41:1890-6.
Demographic variables
Age (years)
< 23 98 (11.6) 846 1.00 -
23 - <26 83 (12.1) 686 1.05 0.77, 1.44
26 - <33 121 (12.0) 1006 1.04 0.61, 1.3
33+ 84 (9.8) 857 0.83 0.61, 1.13
Ethnicity (mother tongue)
Urdu 151 (9.2) 1659 1.00 -
Sindhi 227 (13.5) 1687 1.54 1.24, 1.92
Others 7 (14.3) 49 1.65 0.73, 3.74
Education (years in school)
0 191 (11.2) 1711 1.00 -
1-4 59 (14.2) 416 1.32 0.96, 1.80
5-10 103 (11.2) 916 1.01 0.78, 1.30
>10 33 (9.4) 352 0.82 0.56, 1.21
Marital status
Unmarried 161 (10.3) 1561 1.00 -
Married 214 (12.2) 1754 1.20 0.97, 1.50
Separated/Widowed 11 (13.8) 80 1.39 0.72, 2.67
Duration of imprisonment (months)**
<3 74 (8.8) 843 1.00 -
3 - <9 99 (11.7) 846 1.38 1.00, 1.89
9 - <24 101 (12.0) 841 1.42 1.03, 1.95
24 + 111 (13.1) 845 1.57 1.15, 2.15
Risk behaviors
Do you inject drug intravenously?
No 372 (11.4) 3274 1.00 -
Yes 14 (11.6) 121 1.02 0.85, 1.80
Do you share needles?
No 380 (11.3) 3349 1.00 -
Yes 6 (13.0) 46 1.17 0.49, 2.78
Do you have sexual intercourse with a female?
No 83 (6.2) 1349 1.00 -
Yes 303 (14.8) 2046 2.65 2.06, 3.41
Do you have sexual intercourse with more than one female?
No 127 (7.1) 1791 1.00 -
Yes 259 (16.1) 1604 2.52 2.01, 3.16
Do you have sexual intercourse with a prostitute?
No 219 (8.7) 2503 1.00 -
Yes 167 (18.7) 892 2.40 1.93, 2.99
Do you have sexual intercourse with a man?
No 201 (8.1) 2496 1.00 -
Yes 185 (20.6) 899 2.0 2.38, 3.67
Do you have sexual intercourse with more than one male?
No 242 (9.0) 2695 1.00 -
Yes 144 (20.6 700 2.33 2.09, 3.29
Did you have sexual intercourse with a man prior to incarceration?
No 238 (9.0) 2652 1.00 -
Yes 148 (19.9) 743 2.52 2.01, 3.16
Did you have sexual intercourse with a man during current incarceration?
No 352 (10.7) 3284 1.00 -
Yes 34 (30.6) 111 354 2.42, 5.59
Do you think that any of your sexual partner has more than one Sexual partner?
No 218 (9.4) 2309 1.00 -
Yes 168 (15.5) 1086 1.76 1.41, 2.18
Do you think that any of your sexual partners injects drugs?
No 368 (11.1) 3322 1.00 -
Yes 18 (24.7) 73 2.63 1.53, 4.52
How often do you use condom during sexual intercourse?
A/O*** 28 (11.5) 243 1.00 -
Never 358 (11.4) 3152 0.98 0.65, 1.48
* Twenty of the inmates had missing observations on during of imprisonment, therefore, sample size reduced to 3375 for multivariable model.
b** = Partial logistic regression coefficient
Se = standard error of b
CI*** = Confidence interval.
and ever having used condom during sexual intercourse clinic patients are Treponema pallidum, Haemophilus
were significantly (p<0.001) associated with lifetime risk of ducreyi and herpes simplex virus.35 Laboratory tests for the
GUD for this study population in univariate analysis (Table detection of these organisms are relatively insensitive,
1). costly, technically sophisticated, time consuming and are
often not available in clinics where GUD patients are seen
in developing countries.36,37 These difficulties in assessing
Multivariable logistic regression model the etiologic causes of GUD in the developing countries are
The sexual behaviors which were independently associated further compounded by the high incidence of all the
with GUD in final multivariable logistic regression model sexually transmitted causes of GUD, mixed infections and
were having had sexual intercourse with female (adjusted atypical presentation of long-standing diseases.38
OR = 1.7; 95% CI: 1.3-2.3, P=0.0002), had sexual Aforementioned diagnostic limitations have been partly
intercourse with a prostitute (adjusted OR=1.; 95% CI: 1.2- overcome by the introduction of syndromic approach to
2.0, P=0.0008), had sexual intercourse with man (adjusted GUD diagnosis and management worldwide. WHO has
OR=2.2; 95% CI: 1.7-2.7, P=<0.001) and sexual intercourse recommended this syndromic approach for GUD diagnosis
with man during current incarceration (adjusted OR=1.9; in areas with limited resources39 and therefore, was
95% CI: 1.2-2.9, P=0.0071). Finally ethnicity and duration employed in the present study.
of imprisonment were not significantly associated with
GUD. It is known that the STDs are directly related to the patterns
of sexual behavior and these patterns differ significantly
Discussion within continents and even within countries40, we therefore,
Recent evidence suggests that STDs facilitate the investigated the sexual behaviors associated with GUD
transmission of HIV.29 among the STDs GUD has been among incarcerated male inmates in criminal justice system
recognized as a major factor in HIV transmission8,30 and a in Sindh, Pakistan using a cross-sectional study design.
proportion of HIV infections in men attributable to GUD as
high as 75-98% has been reported in Africa.31 Recently, In our final multivariate logistic regression model, the risk
effective treatment of GUD and other STDs has been shown factors associated with GUD included independent effects
to reduce the incidence of the HIV infection in Africa.29 The of sexual intercourse with a female, sexual intercourse with
etiology of GUD varies both geographically and a commercial sex worker, sexual intercourse with a man and
temporally.32-34 The primary agents causing GUD in STD sexual intercourse with a man during current incarceration.
. Exposure suspicion: knowledge of a person's disease In practice most small samples tend to be used in Pakistan,
the majority of reported HIV surveys have used smaller
status may affect the intensity and outcome of the search for
sample sizes (Table 2) and it follows that their estimates of
plausible or acceptable exposure;
HIV prevalence must have wide CI (i.e. the resulting
. Recall bias: questions about specific exposures may be estimates are less precise). For example, one study of 183
asked many times of cases but only one of controls. prisoners revealed 3 infected with HIV, an estimated
prevalence of 1.6% and a CI of 0%-10.0%. Conversely, a
Other study among intravenous drug users (sample size = 77)
. Positive results bias: studies which show evidence of a revealed no HIV infections, yet the CI were 0%-6.0%. Table
3 illustrates sample size requirements needed to detect a
problem (e.g. HIV-positive individuals) are more likely to
statistically significant change (P<0.05) in prevalence
be submitted and accepted for publication than those which
between two points in time.20 Based on Table 2, neither of
do not, thereby potentially distorting the apparent frequency
the two studies illustrated, if repeated after a specified
of the problem.
interval, would be adequate in size to reveal a statistically
significant difference in prevalence with desirable CI.
Table 4. Sample size required to detect a 20% prevalence change at
95% confidence intervals and varying power.
Therefore, far larger sample sizes than we have seen to data
Power Sample size required to detect a
for HIV studies in Pakistan are required to detect differences
(%) 20% prevalence change from: over time. Table 4 is based on two reported studies of HIV
2.0% to 2.4% * 0.06% to 0.07% b from Pakistan. It shows the inadequate power that one of
these studies (on 302 seafarers) would have if it were
80 21,605 1,039,594 repeated in an attempt to determine an increase in prevalence
70 17,095 821,725
50 10,826 518,872 of 20.0% from 2.0% to 2.4% over a given time period. The
20 3,848 181,935 second reported prevalence is from the NACP and is based
10 1,702 78,520 on screening carried out over several years, hence a much
7 1,073 48,389
larger sample (1,350,000). Although this appears close to the
3 324 13,290
sample size sufficient to measure a change, the figure is
*Based on a study of 302 seafarers. cumulative and renders this method less than optimal.
bBased on screening by the National AIDS Control Programmes of These observations help us recognize the basic problem of
of ,1350,000 people over several years. studying relatively rare conditions such as HIV in low-
prevalence countries. The alternative is to shift the emphasis
from HIV to measuring behavioural risk factors and more
A critical consideration in any study design is sample size. common STDs. More common STDs would allow more
Assuming that a sample is random, if it is desired to modest sample sizes to be used, treating these in turn as
increase the precision of an estimate, then the sample size "proxies" for the risk of HIV transmission, should it be
must be increased. However, to obtain reasonable introduced into a particular setting.
confidence intervals (CI) when estimating the prevalence of
relatively rare conditions, sample size requirements can
become extreme. For example, a sample size of 250 is Characteristics of an ideal surveillance
needed to provide 95% CI of 1.0%-5.0%. If the observed model
prevalence derived from the sample is 2.0%, the a larger Disease surveillance is defined by the International
sample size of 1000 is required to narrow the 95.0% CI to Epidemiological Association (IEA) as "the continuing
1.0%-3.0% (Table 1).21 scrutiny of all aspects of occurrence and spread of a disease
.
human retroviruses, 1988, 4(2):149-54.
to serve as a baseline against which the impact of 4. Abdul Mujeeb S, Hashmi MRA. A study of HIV antibody in sera of blood
interventions can be assessed. donors and people at risk. J Pak Med Assoc 1988;38(8):221-2.
5. Mujeeb SA, Hafeez A. Prevalence and pattern of HIV infection in Karachi. J
Pak Med Assoc 1996;46:255-8.
Such distinct rationales produce different requirements in 6. Hyder AA, Khan OA. HIV/AIDS in Pakistan: the context and magnitude of
terms of study design, sample size and resources needed to an emerging threat J Epidemiol Comm Health 1998;52(9):579-85.
execute surveys that will combine to provide a basis for 7. Khawaja ZA et al. HIV/AIDS and its risk factors in Pakistan. AIDS,
1997;11(7):843-8.
HIV/STD surveillance.
8. Hakim A, Cleland J, Batti MH. Pakistan Fertility and Family Planning Survey
1996-97. Preliminary report. Islamabad, National Institute of Population
Conclusion Studies and London, Centre for Population Studies, London School of
Hygiene and Tropical Medicine, 1998.
Based on the foregoing considerations, we advocate a 9. UNAIDS country profile, Pakistan. Geneva, UNAIDS, 1999.
formal sentinel surveillance system to capture three levels 10. Cleland J, Ferry B. Sexual behaviour and AIDS in the developing world.
of disease risk (low, medium and high) in different Geneva, World Health Organization, 1995.
11. Malik A, Tariq WUZ. Dilemma of spread of AIDS. Pak J Pathol
population sub-groups. The overall design consists of a 1993;4:79-80.
framework within which various types of studies and their 12. Kayani N, et al. A view of HIV-1 infection in Karachi. J Pak Med Assoc
products interrelate to produce an assessment of 1994;44(1):8-11.
behavioural risk factors and the occurrence of STDs 13. Kakepoto GN, et al. Epidemiology of blood-borne viruses: a study of healthy
relevant to defined geographic areas. Examples of blood donors in southern Pakistan. Southeast Asian J Trop Med and Public
Health 1996;27(4):703-6.
subgroups that could form part of a sentinel surveillance
14. Baqi S, et al. HIV-1 antibody seroprevalence and associated risk factors
network include: antenatal clients (low risk), migrant among prison inmates in Sindh, Pakistan. Paper presented at the 1st
workers (medium risk) and STD clinic attendees (high risk). National Symposium, the Aga Khan University, Karachi, Pakistan, 4-14
Sample size should be sufficient to allow calculation of September 1994.
estimates of prevalence and underlying risk in relation to 15. Kha AJ et al. Prison inmates in Sindh: their knowledge and attitudes towards
HIV-related risk behaviour. Paper presented at the 2nd National Symposium,
person, place and time. Further, the system will ideally The Aga Khan University, Karachi, Pakistan, September1995.
measure trends in underlying behavioural risk factors, or 16. Khan AJ et al. Prevalence of sexually transmitted diseases among long-
shifts in the prevalence of more common STDs through distance truck drivers in Pakistan. Paper presented at the 2nd National
repeat surveys at sentinel sites. The sentinel surveillance Symposium, The Aga Khan University, Karachi, Pakistan, September 1995.
system can be evaluated periodically on the basis of the 17. Baqi S. HIV seroprevalenc and risk factors in drug abusers in Karachi. Paper
presented at the 2nd National Symposium, The Aga Khan University,
eight attributes listed earlier. Using data from such a system, Karachi, Pakistan, September 1995.
demographic and risk-factor projection models can be 18. Baqi SA et al. HIV antibody seroprevalence and associated risk factors in sex
applied in order to predict the future disease burden in both workers, drug users and prisoners in Sindh, Pakistan. J Acquired immune
health and economic terms, which has implications for deficiency syndromes and human retrovirology, 1998;18(1):73-9.
public policies such as health and social sector resource 19. Khan OA, Hyder AA. HIV/AIDS among men who have sex with men in
Pakistan. Sexual health exchange, 1998, 2.
allocations.
20. Raza MI et al. Knowledge, attitude and behaviour towards AIDS among
educated youth in Lahore, Pakistan. J Pak Med Assoc 1998;48(6):179-82.
Finally, STDs other than HIV are important in their own
21. Guidelines for sexually transmitted infections surveillance. Geneva, World
right so that the development of integrated sentinel Health Organization, 1999.
surveillance will also address this public health need. 22. Last JM, ed. A dictionary of epidemiology, 3rd ed. New York, Oxford
University Press, 1995.
Acknowledgement 23. Thacker SB, Parrish RG, Trowbridge Fl. A method to evaluate systems of
epidemiologic surveillance. World health statistics quarterly, 1988;41:11-8.
An earlier version of this paper was presented at the 6th
24. Klaucke DN et al. Guidelines for evaluating surveillance systems. Morbidity
Congress of the Asia Pacific Association of Societies of
and mortality weekly report, 1988;37(Suppl. S5):1-20.
Pathologists, 25-28 November 1999, Karachi, Pakistan.
25. Betts CD, Zacarias F. Surveillance for HIV, AIDS and STDs. In: Lamptey P
et al, eds. The handbook for AIDS prevention in the Caribbean. Research
References Triangle Park, North Carolina, Family Health International, 1992.
1. The World Health Report1998. Life in the 21st century. A vision for all. 26. Reproductive tract infections. A set of fact sheets. Thailand, The Population
Geneva, World Health Organization, 1998. Council Incorporated, 1999.
women in general. 9. Khanani R. Memon AR, Shaikh RB, et al Beta lactamase producing Neisseria
gonorrhea strains in Karachi. J. Pak. Med Assoc, 1994;44:70-1.
10. Hashwani S. Hiran T, Fatima M. Awareness of sexually transmitted diseases
Education is the only way to dispel myths and in a selected sample in Karachi. J. Pak Med. Assoc. 1999;49:161-4.
misperceptions about sex and sexually transmitted 11. Ministry of Health. HIV/AIDS in Pakistan A situation and response analysis.
infections. And results of this study suggest that an unmet Islamabad: Islamabad, 2000., pp.23-26.
need for sex education exists as does the need for preventive 12. Raza MI, Afifi A, Choudhry AJ, Khan HI. Knowledge, attitude and behavior
towards AIDS among educated youth in Lahore Pakistan. J. Pak. Med Assoc,
health education for sexually transmitted diseases including
1998;48:172-82.
AIDS in Pakistan. There is a need to conduct population-
13. Lwanga SK, Lemeshow S. Sample size determination in Health Studies: a
based studies in men and women, for elucidating the level Practical Manual, Geneva: WHO 1991,1,25.
and correctness of knowledge about STIs. 14. Lwanga SK, Lemeshow S. Sample size determination in Health Studies: a
Practical manual. Geneva: WHO, 1991, p. vii.
Acknowledgements 15. Blake J. Pediatric and adolescent gynecology. In; Copland LJ, Jerrell JF,
McGregor JA, Dodson R, (eds). Textbook of gynecology. Philadelphia: W.B
We wish to thank our interviewers, Drs. Zubia Mushtaq, Saunders, 1993, p. 613.
Occupation % %
proper training. 5. Rehman K, Akhtar A, Haider Z, et al. Prevalence of sero markers of HBV,
HCV in health care personnel and apparently healthy blood donors. J Pak Med
Assoc 1996;46: 152-54.
Acknowledgements 6. Zuberi SJ, Samad F, Lodi T, et al. Hepatitis and HBsAg in health care
We thank the head of each department for their cooperation. personnel. J Pak Med Assoc 1977; 27:373-75.
We are grateful to the health staff who participated in this 7. Hasan M.A, Rehman K Prevalence of HBsAg among health care workers in
a general hospital. Pak J Med Res 1991;30:98-100.
study. We thank the principal Prof. Illahi Buksh Soomro,
8. Grandy C. The search for an AIDS vaccine: ethical issues in the development
Medical Superintendent of Civil Hospital Karachi, for
and testing of preventive HIV vaccine. Bloomington: Indiana University
allowing us to conduct this study after approval of the Press, 1995, p. 193.
ethical committee of the Institute. We are obliged to Dr. 9. Celebunders R, Ndumbe P. HIV testing in developing countries : viewpoint.
Ahmer for helping us in the collection of the samples. Lancet 1993;342:601-2.
Community Respondents believe that Respondents consider extramarital Radio and TV are main source
majority are unaware sex, blood transfusion, sharing syringes for HIV information Hakim and
Believes that STI are uncommon as risk factors for HIV Quacks are source of information
among married and adolescent STIs causes are not known Community workers are not
Stigma acts as a barrier to considered as source
STIs information
Health Believe that STIs are common Health workers also aware of risk Workers said that they provide
workers Workers believe STIs are factors for HIV information on HIV and STIs
uncommon among adolescents to community.
male motivators alongwith the female health workers may 6. Seema S, Shahana UK, Azra S. Prevalence of Chlamydia trachomatis
infections in Karachi, Pakistan. Jap J Med Sci Biol 1991;44:239-43.
be a step in the right direction. 7. Akhtar S, Luby SP, Rahbar MH. Risk behaviours associated with urethritis in
prison inmates, Sindh. J Pak Med Assoc 1999;49:268-73.
In circumstances where there are severe economic pressure 8. Raza Ml, Afifi A, Choudry AJ, Khan HI. Knowledge, attitude and behaviour
on a large number of community members to provide even towards AIDS among educated youth in Lahore, Pakistan. J Pak Med Assoc
1998;48:179-82.
the most basic necessities of life, the necessity of condom 9. Pakistan Ministry of Health, Ministry of Population Welfare, National
use or the danger presented by poor infection control reproductive health package for health and population welfare service
procedures at health clinics are, perhaps, not perceived as delivery outlets. Islamabad: 1999.
10. Ronald OV, Vincent CA, Donna P. Frank AB. The relationship between
immediate concerns. It is necessary to incorporate the health
women's attitudes about condoms and their use: implications for condom
messages about the causes of STIs and their prevention, promotion. Am J Public Health 1989;79:499-501.
particularly in those programs that reach out to the 11. Fikree F Reproductive health in Pakistan: what do we know? Paper presented
communities. at the Conference on "Pakistan's Population Issues in the 21st Century".
Karachi: Population Council The Aga Khan University; October 24-26, 2000.
12. Luby SP, Niaz O, Siddiqui S, et al. Patients' perceptions of blood transfusion
Acknowledgements risks in Karachi, Pakistan. Int J Infect Dis 2001;5:24-6.
13. Stretcher VJ, Rosenstock IM. The health belief model. In Glanz K, Lewis FM,
This reproductive health needs assessment research was Rimar BK. (eds.). Health Behaviour and Health Education. Theory, research
conducted by the research team from the Aga Khan and practice, 2nd ed. San Francisco: Jossey-Bass Pub 1997.
University on behalf of Marie Stopes Society, Pakistan. The 14. Family Care International. Sexual and reproductive health: briefing, cards
New York, 1999.
research was sponsored by the Department of International
15. Khandwalla HE, Luby S, Rahman S. Knowledge, attitudes, and practices
Development (DFID), U.K. We are highly thankful to the regarding sexually transmitted infections among general practitioners and
communities, research participants, health care provides, medical specialists in Karachi, Pakistan. Sex Transm Infect 2000,76:383-5.
Socio-demographic
Place of interview
Drug treatment center and prison 44 (19.0) 40 (16.5) 1.0 --
On street 187 (81.0) 202 (83.5) 1.2 0.7-1.9
Religion
Muslims 226 (97.8) 229 (94.6) 1.0 -
Others 5 (2.2) 13 (5.4) 2.6 0.9-7.3
City born
Karachi 104 (45.0) 140 (43.0) 1.0 -
Any other 127 (55.0) 138 (57.0) 1.1 0.8-1.7
Education
Illiterate 128 (55.4) 109 (45.0) 1.0 -
Primary 60 (26.0) 65 (26.9) 1.3 0.8-2.0
Secondary or more 43 (18.6) 68 (28.1) 1.8 1.2-2.9*
Number of children
>3 42 (18.2) 36 (14.9) 1.0 -
1-2 33 (14.3) 40 (16.5) 1.4 0.7-2.7
0 156 (67.5) 166 (68.6) 1.2 0.8-2.0
Household members
0-5 68 (29.4) 46 (19.0) 1.0 -
>6 163 (70.6) 196 (81.0) 1.8 1.2-2.7*
Social network
Marital Status
Married 71 30.7 70 (28.9) 1.0 -
Unmarried 160 (69.3) 172 (71.1) 1.1 0.7-1.6
Residence
Fixed residence 102 (47.7) 112 (52.3) 1.0 -
No fixed residence 129 (49.8) 130 (50.2) 0.92 0.6-1.3
Economic conditions
Employment status
Temporay 202 (87.4) 193 (79.8) 1.0 -
Regular employment 17 (7.4) 31 (12.8) 1.9 1.0-3.6*
Unemployed 12 (5.2) 18 (7.4) 1.6 0.7-3.3
Sources of income
Legal means 182 (78.8) 158 (65.3) 1.0 -
Illegal means 49 (21.2) 84 (34.7) 2.0 1.3-3.0
Monthly income (Rupees)
< 2000 114 (49.4) 124 (51.2) 1.0 -
> 2000 117 (50.6) 118 (48.8) 0.9 0.6-1.3
Sexually Transmitted Diseases
Syphilis -
No 229 (99.1) 239 (98.9) 1.0 -
Yes 2 (0.9) 3 (1.2) 1.4 0.2-8.7
Gonorrhea
No 209 (90.5) 211 (87.2) 1.0 -
Yes 22 (9.5) 31 (12.8) 1.4 0.8-2.5
Genital herpes
No 216 (93.5) 196 (81.0) 1.0 -
Yes 15 (6.5) 46 (19.0) 3.4 1.8-6.2
Others
Thought of committng suicide
No 209 (90.5) 198 (81.8) 1.0 -
Yes 22 (9.5) 44 (18.2) 2.1 1.2-3.7*
to those seeking results. males with mean age of 30.95 ± SD 8.4 years. The majority
Statistical Analysis 215 (45.5%) were recruited from district Central of Karachi.
About 50% of the participants had no formal education and
Descriptive analysis was done by calculating means (+
83% were working as temporary employees. We also found
standard deviation) for continuous and proportions for
that 312 (66%), 141 (29.8%) and 20 (4.2%) subjects were
categorical variables. Univariate analysis was performed by
single, currently married and separated or divorced
applying Chi-square and Fisher exact tests for categorical
respectively (Table I).
variables. To observe the independent effect of individual
factors, the potential confounders were controlled by means Factors associated with Injecting drug use
of logistic regression analysis and adjusted odds ratios Table 2 shows results of univariate analysis with socio-
(AOR) with their 95% confidence interval (CIs) were demographic, economic and social network related factors
obtained.16 All variables with p-value of <0.2 in univariate taken as exposures against mode of drug use as outcome.
analysis were included in the multivariate analysis.
Statistical program Epi-Info 6 was used to enter the data and The multiple logistic regression analysis (Table 3). showed
analysis was performed using Statistical Package for Social source of income generation([Illegal vs legal; AOR 1.6,
Sciences.17,18 95% CI 1.0-2.6), sharing of income with family (No vs Yes;
AOR 1.7, 95% CI 1.1-2.7) and having suicidal thoughts(Yes
Results vs No; AOR 2.0, 95% CI 1.1-3.8) as factors significantly
We interviewed 473 drug users, among them 389 (82.2%) associated with injecting drug use. In addition, subjects
were found on streets and 84 (17.4%) were recruited from living in district Central, East and West were more likely to
rehabilitation centers or prison. Among drug users, 242 inject the drug compared to individuals living in district
were IDUs and 231 were non-IDUs. All subjects were South. Similarly, genital herpes was more common in IDUs
1. PANOS. HIV and injecting ding use in developing countries. AIDS 16. Barker DJ, Hall AJ. Practical epidemiology. 4th ed. Edinburgh: Churchill
information Fact sheet-21, I998, p.1.
Livingstone, 1991, p. 38.
2. Ahmad B, Mufti KA, Farooq S. Psychiatric comorbidity in substance abuse
(opiods). J Pak Med Assoc 2001;51:183-6. 17. Statistical Package for Social Sciences Release. 10.0 1989-1999, Copyrights
@ SPSS Inc, Chicago, IL, USA.
3. Pakistan Narcotics Control Hoard. National Survey on drug abuse in
Pakistan. Islamabad. I986. p.iii. 18. Dean AG, Dean JA, Coulombier D, et al. Epi Info Version 6: a Word-
4. World Health Organization. Fact sheet No. 127: Trends in substance use and Processing, Database and statistics program for public health on IBM
associated health problems. [Online] I996. [cited 2003. January 10] Available compatible microcomputer. Atlanta. Georgia: Centers for Disease Control and
from:URL:http//www.who.int/inffs/en/fact127.html. WHO/1996/127). Prevention, USA. 1995.
5. UNAIDS. YOUANDAIDS: The HIV/AIDS portal for Asia Pacific, UNDP. 19. Altaf A. Reducing the risk of injecting related harm in Karachi: a pilot project.
[Online] 2003. [Cited 2003, February 22]. Available Department of Community Health Sciences. The Aga Khan University,
from:URL:http://w\vw. youandaids. org/Themes/Injecting Drug Use asp.
Karachi, [Unpublished] 2001.
6. Jarlais. D.C. Hagan. H., riedman, SR. et al. maintaining low HIV
seroprevalence in populations of injecting drug users. JAMA 20. UNDCP, HIV and development programme. HIV and injecting drug use: a
I995;274:l226-3l. challenge to sustainable human development [Online] 2000, [Cited 2003,
7. World health organization. Statement from the consultation for HIV infection. April 01]. Available from: URL: http://www.undp.org/hiv/
Geneva WHO 1992. publications/deany.htm.
8. UNDCP. Law Enforcement: Central Asia CIRUS - Combined Interdiction 21. Gillis JS, Tareen IA. Chaudhry HR., et al. Risk factors for drug misuse in
Unified Strategy for Iran [online] 2003 [cited 2 (103. January 01)]. Available Pakistan. Int J Addict 1994;29:2l5-23.
from URL Http.www.unodc.org/unodc/law_enforcement_centralasia.html.
22. Rao AV, Vasudevan PM. The course and outcome of drug addiction, a follow-
9. Baqi S, Nabi N, Hasan SN, et al. HIV antibody Seroprevalence and associated
risk factors m sex workers, drug users, and prisoners in Sindh Pakistan. J up study of 178 cases in Madurai, South India. Drug Alcohol Depend
Acquire Immune Defic Syndr Hum Retroviral 1998;18:73-9. 1980;6:351-7.
10. Gillis J,. Mubbashar MH. Risk factors for drug abuse in Pakistan, a 23. Shah SA, Khan OA, Kristensen S, el al. HIV infected workers deported
replication. Psychol Rep 1995;76:99-108. from the Gulf States; impact on Southern Pakistan. Int J STD AIDS
11. Strathdee S,. Patrick DM, Curries SL, et al. Needle exchange is not enough 1999;10:812-14.
lessons from the Vancouver injecting drug user study. AIDS 1997;11:F59-65. 24. Hyder AA, Khan OA. HIV/AIDS in Pakistan, the context and magnitude of
12. Song JY, Safaeian M, Strathdee SA. et al. The prevalence of homelessness an emerging threat, J Epidemiol Community Health 1998; 52:579-85.
among injecting drug users with and without HIV infection. J. Urban Health
2000; 77:678-87. 25. Kakepoto GN, Bhally HS, Khaliq G, et al, Epidemiology of blood borne
viruses: a study of healthy blood donors in Southern Pakistan. Southeast
13. Strathdee SA, Patrick DM, Archibald CP. Social determinants predict needle
sharing behaviour among injection drug users in Vancouver. Canada Asian J Trop Med Public Health 1996; 27}:703-6,
Addiction 1997; 92:1339-47. 26. Baqi S, Kayani N, Khan J.A. Epidemiology and clinical profile of HIV/AIDS
14. Government of Sindh. Development Statistics of Sindh, Pakistan 1994. in Pakistan. Trop Doct 1999;29:144-8.
Background: To evolve effective prevention and efficient years, 60% were married, 58.3% urbanites, 81.7% living
treatment strategies for sexually transmitted infections with their families and 83.3% smokers. Only 10.5% were
(STIs) in a country, comprehensive understanding of the drug addicts. Out of 465 cases, 27.5% cases had gonorrhea,
prevalent STI and their modes of transmission is needed. 31.6% syphilis, I7.2% chancroid, 18.3% herpes, 5.2%
The aim of this present study was to generate such data for chlamydial infections while only one case (0.2%) was HIV
Pakistan. positive. Most men (55%) acquired the infection
Methods: The study was conducted between June 1999 and heterosexually, 11.6% through homosexuality, I8.4%
September 1999 in four provincial capitals. In each city, through bisexual relations and 2 men (0.5%) reported
data was collected from one or more teaching hospitals and bestiality. Among 78.1% of those contracting the infection
a number of general practitioners. During this period, 465 heterosexually, the source of infection was a sex worker.
men suffering from STIs were interviewed. None acquired infection through his wife. The knowledge
Results: The mean age of study population was 31.9+8.6 about STIs was very poor. Wrong notions were prevalent.
Disease Number Percentage Whereas 55% men said that they did not know the cause of
this infection, 43.3% knew that they had acquired this
Syphilis 147 3 1 .6
Gonorrhoea 128 27.5
infection through sexual contact. Only 1.7% attributed their
1 Icrpes 85 18.3 condition to God's will (Table 5).
Chancroid 80 17.3
Chlamvdia 24 5.2
H1V 1 0.2 Nearly all men (93.3%) knew that the infection could be
prevented. However, only 16.7% were aware that the
prevention lies in practicing safe sex. Majority of them
Types of Sexually Transmitted Infections (65%) thought that the disease could be prevented through
Out of 465 cases, 27.5% cases had gonorrhea, 31.6% had
some vaccination (Table 5).
syphilis, 17.2% chancroid, 18.3% herpes, 5.2% various
forms of chlamydial infections while only one case (0.2%) Source of treatment
was HIV positive. He was working in Saudi Arabia and Three hundred and seventeen persons (68.2%) had sought
reported having acquired the infection there (Table 2)
some treatment for their ailment before the interview. Out of
them 33.4% had gone to the hospital, 55.3% to a private
There was not much variation in the pattern of STIs in four
cities (Table 3). The only significant finding was a higher health care provider practicing modern medicine, 8.6% to
percent (37.6%) of gonorrhea in Peshawar as compared to traditional healers and 2.7% to Homeopaths (Table 6).
Table 3. Distribution of STIs according to area (n=465).
City No. of cases Syphilis (%) Gonorrhoea (%) Chancroid (%) Herpes (%) Chlamydia (%) HIV+ (%)
Source of infection
Sexual contact 201 43.3
God's will 8 1.7
Do not know 256 55.0
Prevention of STIs
Prevention possible 434 93.3
Do not know 31 6.7
Preventive Measure
Safe sex 78 16.7
Vaccination 302 65.0
Do not know 85 18.3
Summary
Our objective was to describe HIV/STD risk behaviours and In conclusion, high-risk sexual behaviours are prevalent
awareness among a community-based sample of drug users among male drug users in Pakistan, and awareness of
in Pakistan. Drug users contacted through street outreach by transmission risks is low. These data attest to the urgent
need for effective and specific interventions in Pakistan to
a non-governmental organization in Quetta, Peshawar and
prevent transmission of HIV and STDs among drug users
Rawalpindi underwent interviewer-administered
and their sex partners (I J STD & AIDS 2004;15:601-7).
questionnaires. Descriptive statistics were used to
characterize sexual behaviours by city, marital status and
the use of injection drugs. Logistic regression was used to
Introduction
identify correlates of ever having an STD. The first reported case of AIDS in Pakistan was in 1987.1,2
Since than, the number of HIV cases has increased to
approximately 100,000 among the country's population of
Of 608 drug users studied, all but one was male; median age
145 million.3 This suggests that the number of reported
was 32 years and 45% had no formal education. Half were
cases of HIV is still relatively low among the general
married, of whom 25% were living with their wives. Sexual
population. These findings are consistent with most reports
behaviours were reported as follows: 14% had sex with among high risk population such as sex workers, truck
other males, 28% reported sex with males and females, 49% drivers and persons seeking treatment for STDs.4,5 UNAIDS
had paid money to have sex and only 10% had ever used currently characterizes Pakistan as a country of high-
condoms. One-fifth reported having had an STD and about risk/low-prevalence.6
40% reported having suffered from either one or more STD-
related symptoms. Only 41% had heard about HIV/AIDS, Although estimates of HIV prevalence among injection
of whom 17% knew that HIV/AIDS could be transmitted drug users (IDUs) have typically ranged from 0-2%6,7,
through sexual contact. prevalence of hepatitis C virus among IDUs in the same
Age (years)
20 or less 23 (7.62) 5(3.21) 9 (6.00) 37 (6.09) 0.021
21-30 139 (46.03) 72 (46.15) 50 (33.33) 261 (42.93)
31 or more 140 (46.36) 79 (50.64) 91 (60.67) 310 (50.99)
Education
No education 118 (39.20) 87 (55.77) 66 (44.00) 271 (44.65) <0.001
5 or less years 106 (35.22) 28 (1 7.95) 29 (19.33) 163 (26.85)
6-1 0 years 71 (23.59) 32 (20.51) 52 (34.67) 155 (25.54)
11 or more years 6 (1.99) 9 (5.77) 3 (2.00) 18 (2.97)
Married
Yes 150 (50.1 7) 68 (43.59) 48 (32.21) 266 (44.04) 0.001
No 149 (49.83) 88 (56.41) 101 (67 79) 338 (55.96)
Living arrangements
Alone 68 (24.37) 62 (47.33) 91 (61.49) 221 (39.61) < 0.001
Wife and children 40 (14.34) 15 (11 .45) 12 (8,11) 67 (12.01)
Others 171 (61 29) 54 (41.22) 45 (30.41) 270 (48.39)
Sexual partners
Any sex with:
Women 85 (80.19) 59 (80.82) 60 (84.5 1 ) 204 (81.60) 0.504
Boys 16 (15.09) 11 (15.07) 11 (15.49) 38 (15.20)
Men 5 (4.72) 2(2.74) 0 7 (2.80)
Eunuchs 0 1 (100) 0 1 (100)
Condom use
Ever 15 (8.77) 9 (9.47) 11 (11.70) 35 (9.72) 0.740
Never 156 (91.23) 86 (90.53) 83 (88.30) 325 (90.28)
Knowledge of HIV/AIDS
transmission
None 229 (75.83) 122 (78.21) 104 (69.33) 455 (74.84) 0.418
Through sex 49 (16.23) 25 (16.03) 32 (21.33) 106 (17.43)
Through needle-sharing 24 (7.95) 9 (5.77) 14 (9.33) 47 (7.73)
* Fisher's exact test. Missing values [education (1); married (4); living arrangements (50); sexual partners (248); reported STD (116); condom use (248);
heard about HIV/ AIDS (1); tested for HIV/AIDS (11)]
Behavior IDUs (n=92) Non-IDUs (n = 512) Total (n = 604) P-value (X2 test)
Sexual behaviour
Heterosexual 32 (54.24) 172 (57.14) 204 (56.67)
Homosexual 5 (8.47) 44 (14.62) 49 (13.61) 0.247
Bisexual 22 (37.29) 85 (28.24) 107 (29 72)
Condom use
Ever 10 (15.87) 25 (8.45) 35 (9.75) 0.071
Never 53 (84.13) 271 (91.55) 324 (90.25)
Knowledge of HIV/
AIDS transmission
None 61 (66.30) 391 (76.37) 452 (74.83) 0.012
Through sex 17 (18.48) 88 (17.19) 105 (17.38)
Through needle-sharing 14 (15.22) 33 (6.45) 47 (7.78)
(n=490), 22% reported ever having had an STD, 56% behaviours. In particular, nearly half of the sample reported
reported having had pus in urine, 11% had sores in the having paid to have sex, and nearly one-third reported
genital area and 29% boils/lumps or itching in the genital having had sex with both females and males in their
area. lifetime. Our data indicate the potential for transmission of
HIV or STDs to the sexual partners of drug users, since
A total of 41% of respondents had heard about HIV/AIDS; almost half of this population was married. Indeed, in a
of these, only 17% knew that HIV/ AIDS could be recent study of IDUs in Manipur, Panda and colleagues
transmitted through sexual contact. Very few (15.2%) of found that 45% of their wives were HIV seropositive.18
IDUs knew that HIV/AIDS could be transmitted through
needle/syringe-sharing. HIV/AIDS awareness was highest Although reports of sexual intercourse with commercial sex
in Rawalpindi (69%) compared with Peshawar (38%) and workers are common in many parts of Asia19,22, data on
Quetta (28%) (P<0.001). Only 2% of the respondents had homosexual behaviours are sparse. In our study, 15% of
male drug users reported engaging in sex with boys. In these
ever knowingly received an HIV antibody test.
cities, study staff reports that it is not uncommon for male
drug users to have sexual relationships with street-involved
Discussion children, who are often boys.
In our study of male drug users in three Pakistani cities, we
found very low levels of condom use and HIV/AIDS In an earlier study in Pakistan, 11% of truck drivers reported
awareness coupled with evidence of high-risk sexual having sex with male commercial sex workers. 17 In
example, within the context of marriage. 2. Mujeeb SA, Hashmi MRA. A study of HIV-antibody sera of blood donors and
people at risk. J Pak Med Assoc 1988;38: 221-2.
3. Khan OA, Hyder AA. Responses to an emerging threat: HIV/AIDS policy in
In our study, respondents reported high-risk behaviours that Pakistan. Health Policy Plan 2001;16; 214-8.
could facilitate the spread of heterosexual STD and HIV 4. Hyder AA, Khan OA. HIV/AIDS in Pakistan: the context and magnitude of
an emerging threat. J Epidemiol Comm Health 1998;52:579-85.
infection. The lack of awareness of HIV/AIDS transmission
5. Kazi BM, Ghaffar A, Salman M. Health care systems in transition III.
routes, and misconceptions about the disease, may further Pakistan, Part II. Pakistan's response to HIV-AIDS. J Pub Health Med
contribute to continued high-risk behaviours by segments of 2000;22:43-7.
the population and thus, to the spread of HIV/STDs. 6. United Nations Office for Drug Control and Crime Prevention (UN-ODCCP)
and UNAIDS. Baseline Study of the relationship between injection drug use,
Pakistan's proximity to India, where HIV/AIDS is a HIV and hepatitis C among male injection drug users in Lahore. New York:
growing issue increases the fears of a future epidemic in UNCCP, 1999.
Pakistan. In order to avert an HIV/AIDS epidemic, 7. Baqi SA, Sharaf Ali Shah, Baig MA, Mujeeb SA, et al. Seroprevelence of
HIV, HBV and syphilis and associated risk behaviours in male transvestites
Pakistani society needs to be tolerant and develop a better (Hijras) in Karachi Pakistan. Int J STD AIDS 1999:10:300-4
understanding of drug users. The country must also address 8. Poshyachinda V. Drug injecting and HIV infection among the population drug
the issues of public ignorance regarding HIV/STDs and face abusers. Asia Bull Narc 1993; 45:77-90.
the realities of bisexuality, homosexuality, child sexual 9. Weniger BG, Brown T. The march of AIDS through Asia. N Engl J Med
1996:335:343-5.
abuse, drug addiction and prostitution. 10. United Nations Office for Drug Control and Crime Prevention. Global illicit
drug trends. New York: UNDCP, 2002.
Thus far, initiatives at governmental or nongovernmental 11. Drug Abuse Prevention with young people in Peshawar, North West Frontier
Province (NVVFP) in Pakistan; Peshawar WHO conference
level to prevent STD/HIV/AIDS in Pakistan have been [www.who.int/hpr/ onference/products/Casestudi-es/ peshawar.pdf]
minimal. At the time of writing, there was only one needle 12. Zafar T, Hasan SA. Sociodemographic and behavioral profile of heroin users
exchange programme operating in the country, in Lahore. and the risk environment in Quetta, Pakistan. Int J Drug Policy 2002, (In
press).
Literature also suggests that very little is known about
13. Higher level of Needle Sharing Among Injection Drug users in Lahore,
sexual behaviours of drug users and other high-risk Pakistan. In the Aftermath of the US-Afghan war. XIV international
populations in Pakistan. Therefore future research should Conference on AIDS Barcelona Spain, 2002.
focus on determining the sexual behaviours and STD status 14. Family Health International. Monitoring the AIDS Pandemic (MAP) Network
In: The status and trends of the global HIV/AIDS pandemic final report .
among high-risk groups, with representative samples from North Carolina: FHI, 2002.
both genders. Programmes targeted to increase HIV/AIDS 15. Grassley NC, Lowndes, CM, Rhodes T, Judd A, Renton A, Garrett GP.
awareness should be introduced through electronic media, Modelling emerging HIV epidemics: the role of .injecting drug use and sexual
transmission in the Russian Federation Int J Drug Policy 2003:14:25-43.
outreach workers, religious leaders, health workers, friends I6. Tobi J, Saidel DDJ, Wiwat P, et al. Potential impact of HIV among IDUs on
and family members. Vocational training programmes to heterosexual transmission in Asian settings: The Asian epidemic model, Int
empower drug users will improve their chances of returning Drug Policy, 2002 (In press).
back to society as productive members. More treatment 17. Agha S. Potential for HIV transmission among truck drivers in Pakistan AIDS
2000;14:2404-6.
services and counseling services should be introduced. 18. Panda S, Chatterjee A, Bhattacharya SK et al. Transmission of HIV from
Efforts such as these at community and government level injecting drug users to their wives in India. Int J STD AIDS 2000;11:468-73.
are needed to avert a major HIV/AIDS epidemic in 19. Gibney LCP, Khawaja Z, Sarker M, et, al, Behavioral risk factors for
HIV/AIDS in a low-HIV prevalence Muslim national: Bangladesh. Int J STD
Pakistan. AIDS 1999;10:186-94.
20. Caldwell B, Pieris I, Barkat e K, et al. Sexual regimes and sexual networking: the
risk of an HIV/AIDS epidemic in Bangladesh. Soc Sci Med 1999;48:1103-16 .
Acknowledgements 21. Singh S, Crofts N. HIV infection among injecting drug users in north-east
Malaysia 1992. AIDS Care 1993; 5:273-81.
This project was supported in part by the National Institute
22. Bishop GD, Kok AJ, Chan RK. Sexual practices among men attending an
on Drug Abuse, grant number DA09225. Support for Nai anonymous HIV testing site in Singapore. AIDS Care 1998;10(Suppl
Zindagi was provided in part by the European Commission. 2):S167-78.
The authors are indebted to Nai Zindagi staff and clients 23. Wohl AR, Johnson DF, Lu S, et al. HIV risk behaviours among African
American men in Los Angeles County who self-identify as heterosexual. J
who made this project possible, as well as Dr Mohammad Acquir Immune Defic Syndr 2002;31:354-60.
Abrer Ahmed and Joseph Bareta for assistance with data 24. Francesca E. Aids in contemporary Islamic ethical literature. Med Law
management. We would also like to thank Professor 2002;21:381-94.
Jonathan M. Zenilman, Johns Hopkins University for his 25. Ali S, Khanani R, Tariq WU. Understanding the context of HIV/AIDS
infection in Pakistan. Venerology 1995;8:160-3.
suggestions on interpreting these data. 26. Lynn W. Pakistan launches media blitz on AIDS. Global AIDS News
1994;2:l-2.
References 27. Gray RH, Wawer MJ, Sewankambo NK, et al. Relative risks and population
attributable fraction of incident HIV associated with symptoms of sexually
1. Khanani RM, Hafeez A, Rab SM, Rasheed S. Human immunodeficiency transmitted diseases and treatable symptomatic sexually transmitted diseases
virus-associated disorders in Pakistan. AIDS Res Hum Retroviruses in Rakai District, Uganda. Rakai Project Team. AIDS 1999;13:2113-23.
This study was conducted as screening for the presence of Mekran 3000 25 (0.83%) 3 (0.1%) 22 (0.73%)
antibodies against HIV-I/2 in the province of Balochistan Quetta 1000 10 (1.0%) 3 (0.3%) 7 (0.70%)
and to determine the frequency of false-positive results Sibi 350 4 (1.1%) 2 (0.57%) 2 (0.53%)
Naseerabad 300 5 (1.6%) 1 (0.33%) 4 (1.27%)
during screening in blood banks in public sector. Zhob 250 3 (1.2%) 2 (0.8%) 1 (0.40%)
Kalat 100 1 (1%) Nil 1 (1.0%)
Total 5000 48 (0.96%) 11 (0.22%) 37 (77.0%)
Material and Methods
The study was conducted in all the six divisions of * Strategy I, II and III as recommended by UNAIDS / WHO.
Balochistan, i.e. Sibi, Zhob, Quetta, Kalat, Makran and
Naseerabad, from January - December, 1999. Five thousand
In Makran, 25 (0.83%) subjects were labeled HIV positive
subjects were screened for the presence of antibodies
on Strategy 1 while only 3 (0.1%) actually came out to be
against HIV-1/2 during this period. The subjects were
positive on Strategy 2 and 3. In Quetta, 10 (1.0%) were
voluntary blood donors. Screening was done observing found positive on Strategy I but only 3 (0.3%) were truly
Strategy I. All HIV positive cases on Strategy I were positive on ELISA. In Sibi 4 (1.1%) subjects were labeled
retested, in the referral laboratory in public sector, on as positive on rapid testing while 2 (0.57%) showed positive
ELISA observing Strategy II and Strategy III, as per results on Strategy II and III. In Naseerabad, there were 5
guidelines of UNAIDS/WHO.7-13 Strategy I was a rapid test (1.6%) subjects who were found to be positive on Strategy
and was performed on Capilus HIV 1/2 by 1. Only one, (0.33%), showed persistent positive results on
Cambridge, Ireland. Strategy II (ELISA) was performed on Strategy 2 and 3. In Zhob, 3 (1.2%) subjects had the label of
Lab System HIV 1/2 Finland and Strategy III (ELISA) was HIV positive on rapid testing, while only 2 (0.8%) were
undertaken as a confirmation test performed on Sanofi truly positive on ELISA. In Kalat, only one (1%) subject
Pasture HIV 1/2 France. All the samples underwent the had HIV positive result on Strategy 1. It later proved to be
three strategic testing.14,15 Results were calculated as simple a false positive.
percentages.
While summarizing, there were 48 (0.96%) subjects who
Strategy I is used in serological HIV screening in were picked up as having HIV antibodies on Strategy 1 but
Blood Bank. According to WHO recommendations only 11 (0.22%) were actually infected. Thirty seven (77%)
blood banks having smaller workload, less than 20 subjects did not have the infection but were falsely labeled
donations per day, rapid test is to be adopted. Any sample as HIV positive, as shown in Table.
giving a positive reaction is to be further tested in Strategy-
II, which is ELISA, based in this study. The confirmation of Discussion
the sample as having HIV antibodies is done observing The central issue is the high frequency of false positive tests
strategy-Ill. This is done on ELISA techniques but the kits for HIV infection. Current screening programs use a
used in Strategy-II and Strategy-Ill should have sequence of tests, starting with a rapid testing. Serum
different HIV-1/2 antigen makeup as per instructions of samples yielding positive results are subjected to more
WHO/UNAIDS (1998). Any sample giving a positive complicated and expensive confirmatory testing, typically
result to at least two out of the three strategies tests is with ELISA. A positive confirmatory test is considered
labeled as HIV positive. evidence of HIV infection.
Any sample giving positive reaction to one out of three Bayes' rule allows us to calculate the probability
strategies, test is reported as HIV negative. In such cases that a person with positive tests is infected.6 Imagine
follow-up quarterly tests for one year are recommended and testing 100,000 people, among whom the prevalence of
is the protocol.4 disease is 0.01 percent. Of the 100,000, 10 are infected;
component, which is discarded because of a screen positive 5. Gruson L. AIDS toll in children is called "deadly crisis". New York Times.
April 9, 1987: 88.
result in any of the mandatory screening carries a substantial 6. Mylonakis E, Paliou M, Greenbough TC. Report of false positive HIV result
cost. The bag was procured, the blood group established, and the potential use of additional tests in establishing serostatus. Arch Int
Med2000;l60(15): 2386-7.
HBV, HCV and HIV screening was compulsorily done, and
7. World Health Organization. Biosafety guidelines for diagnostic and research
components, if made, must have gone through extensive laboratories working with HIV. Geneva. WHO AIDS Series No.9: 1991.
procedures. A lot of energy, time and cost were 8. UNAIDS-WHO Joint National Program on HIV/AIDS. Guidelines for
organizing national external quality assurance schemes for HIV serological
incorporated. Now if it was discarded because of a false testing Geneva WHO; 1996.
positive result, the losses on just one bag can be evaluated 9. UNAIDS-WHO Joint United Nations Program on HIV/AIDS. Revised
and multiplied by the number the incidence happens each recommendations for the selection and use of HIV antibody tests. Weekly
epidemiological records. Geneva WHO: 1992; 67:145-149.
year in each blood bank in public sector. It creates other 10. UNAIDS-WHO Joint United Nations Program on HIV/AIDS. Operational
problems too; non-renumerated blood donors are the characteristics of commercially available assays to determine antibodies to
HIV-I and/or HIV-2 in human sera Geneva. WHO. 1998 report No. 9 and 10.
backbone of any blood transfusion service. HIV false
11. Va Dyke E. Meheus AZ.. Piot P. Human immunodeficiency virus in
positive screening results create a panic in this pool. The Laboratory diagnosis of sexually transmitted diseases. World Health
approach of the positive labeled donor for confirmation is Organization report. Geneva 1999; 85-98.
12. UNAIDS-WHO Joint United Nations Program on HIV/AIDS. HIV testing
natural and ethical. When the confirmation is contrary to the methods. Geneva: Technical update:1997.
screening results there is a breach of confidence of the 13. Anderson S. Field evaluation of alternate testing strategies for diagnosis and
donors on the blood bank. The retention of blood donor in differentiation of HIV-1 and HIV-2 infection in an HIV-I and HIV-2
prevalent area. AIDS 1997; 11: 1815-1821.
this scenario is difficult and the donor strength is lost 14. Stetler HC Field evaluation of rapid HIVserological tests for screening and
significantly. The psychological stress to the particular confirmation of HIV-I in Hondouras. AIDS 1997; 11:359-71.
donor, who suddenly hears that his donated blood has given 15. Spielberg F, Kabeya CM, Ryder RW. Field testing and comparative evaluation
of rapid visually read screening assays for antibody to human
reactivity to one of the screening tests and he is to see a immunodeficiency virus. Lancet 1989;333:580-4.
physician for the next step, is self-explanatory. 16. Pauker SG, Kassirer JP. Decision analysis. N Engl J Med 1987;316:250-8.
Editorial
Prevention and Control of HIV/AIDS among Injection Drug
Users in Pakistan: a great challenge
S. A. Shah, A. Altaf*
Enhanced HIV/AIDS Control Program, Government of Sindh and Department of Community Health Sciences, Aga Khan University*, Karachi.
According to the national survey on drug abuse in 1993 the market cannot be used through inhalation and can
there were about three million drug users in the country only be used via injection
representing 2.3% of the total population of Pakistan.1 With 2. Limited availability of heroin (cost effectiveness)
estimated annual growth rate of 6.4%, total number of drug 3. Return of Pakistanis from other countries where they
abusers in the country in 2004 could be estimated to almost have been introduced to injections and where injecting
five million. The 1993 study also estimated that 51% drug drug use is more common.
abusers were taking this narcotic product, the most common 4. Use of psychotropics
drug abused in the country and 93% heroin abusers were
believed to take heroin either by filling in cigarettes or by
inhalation. At that time only 1.8% heroin addicts (mainly in The Challenge ahead
Karachi) administered heroin in the form of injections.1 Research studies conducted around the world clearly
However, according to the results of National Assessment suggest that IDUs are at increased risk of acquiring and
Study on Drug Abuse Situation in Pakistan, conducted in transmitting blood borne infections including HIV/AIDS.
year 2000 it was estimated that about 60,000 drug addicts Moreover, injection drug use is a very efficient mode of
were using drugs through injections. Studies conducted in transmission of HIV and has provoked "kick start" to
2002 with drug addicts at two different localities of generalized HIV epidemic in some parts of the world such
Karachi suggest 80-100% addicts are using heroin via as Manipur, India.4
injections.2,3 There is an increasing shift from inhalation to
injection drug use (IDU) among addicts. Possible reason for Cross sectional studies2,3 conducted among IDUs in
shifting to injection drug use could be one or some of the Karachi documented high risk behaviors such as:
contributing factors: . Sharing of syringes
1. Change in heroin quality - heroin currently available in . Shooting drugs in groups (80%)
. High prevalence of syphilis (13-16%) Above mentioned facts indicate that harm reduction
. Low use of condom (15%) program is not producing the desired results in terms of
preventing HIV/AIDS among this high risk group. The
. Commercial blood donation (19-31%) issue has been carefully and meticulously discussed with
. Indulging in commercial sex (20-30%) service providers, NGOs and other public health specialists
and the consensus is that in the absence of comprehensive
The first reported outbreak of HIV infection in Pakistan rehabilitation program for IDUs including provision of
happened in Larkana, a small town of Sindh province. economic opportunities (skilled or unskilled jobs) and a
Nineteen injection drug users (IDUs) were positive for HIV high relapses rate harm reduction programs will not achieve
infection.5 Continued surveillance by the Provincial AIDS the objectives (prevention of HIV/AIDS among this high
Control Program suggest that this number has increased to risk group).
45 (up to February 2004).
Seroprevalence of HIV, HBV and Syphilis and associated risk behaviors in male
Transvestities (Hijras) in Karachi, Pakistan S-17
S. Baqi, S. A. Shah, M. A. Baig, S. A. Mujeeb, A. Memon
Int J STD AIDS 1999;10:300-304
HIV-infected workers deported from Gulf States: impact on Southern Pakistan S-22
S. A. Shah, O. A. Khan, S. Kristensen, S. H. Vermund
Int J STD AIDS 1999;10:812-14
Seroprevalence of HBV, HCV and HIV infections among College Going first time
Voluntary Blood Donors S-24
S. A. Mujeeb, K. Aamir, K. Mehmood
J Pak Med Assoc 2000;50:269-70
Evaluation of blood bank practices in Karachi, Pakistan and the government's response S-25
S. Luby, R. Khanani, M. Zia, Z. Vellani, M. Ali, A. H. Qureshi, A. J. Khan, S. A. Mujeeb,
S. A. Shah, H. F. Hoch
Health Policy Plan 2000 June;15(2):217-22
Knowledge, attitudes and practices regarding sexually transmitted infections
among general practitioners and medical specialists in Karachi, Pakistan S-31
H. E. Khandwalla, S. Luby, S. Rahman
Sex Transm Infect 2000;76:383-85
Multivariate analysis of risk factors associated with genital ulcer disease among
Incarcerated Males in Sindh S-34
S. Akhtar, S. P. Luby, M. H. Rahbar
J Pak Med Assoc 2000;50:115-20
Prevalence of HIV, Hepatitis B and C amongst Health Workers of Civil Hospital Karachi S-48
S. Aziz, A. Memon, H. I. Tily, K. Rasheed, K. Jehangir, M. S. Quraishy
J Pak Med Assoc 2002;52:92-94
Socio-economic and demographic factors associated with injecting drug use among drug
users in Karachi, Pakistan S-55
A. Agha, S. Parviz, M. Younus, Z. Fatmi
J Pak Med Assoc 2003;53:511-16
High-risk sexual behaviours among drug users in Pakistan: implications for prevention of
STDs and HIV/AIDS S-65
N. Haque, T. Zafar, H. Brahmbhatt, S. G. S. Imam, S. A. Strathdee
Int J STD AIDS 2004;15:601-7
High frequency of False Positive Results in HIV Screening in Blood Banks S-72
A. A. Sheikh, A. S. Sheikh, N. S. Sheikh, R. U. Shan, M. T. Malik, F. Afridi
J Ayub Med Coll Abbottabad 2004;16:28-31
Prevention and Control of HIV/AIDS among Injection Drug Users in Pakistan: a great challenge S-75
S. A. Shah, A. Altaf
J Pak Med Assoc 2004;54:290-91
An outbreak of HIV infection among injection drug users in a small town in Pakistan: S-77
potential for national implications
S. A. Shah, A. Altaf, S. A. Mujeeb, A. Memon
Int J STD AIDS 2004;15:209
JOURNAL OF THE PAKISTAN MEDICAL ASSOCIATION (JPMA)
Vol: 55
PMA House, Aga Khan III Road, Karachi-74400, Pakistan
Telephone/Fax No. 2226443, Telegram: AVICENNA
In Pakistan Rs.150.00
Overseas countries US$ 25.00
Remarks
4. Supply will be continued for another year when subscription is received well in advance.