Daily Times

As we observe the World AIDS Day this year in Pakistan, under the shadow of the second phase of the COVID-19 pandemic and another silent pandemic of Tuberculosis, let us do so with a resolve to ensure continuity of priority health services, come hail, rain or sunshine. While Pakistan acquitted itself admirably in the first phase of the epidemic with considerably low morbidity or mortality in relation to all its neighbors and other countries of the world, the few glitches included suspending routine health services, at considerable loss to our overwhelmed and somewhat frail health system. Let us also remain mindful of a sizable number of health care professionals and providers who lost their fight against COVID-19 and died while giving their best to the system. The medical profession lost some of its greatest stalwarts including clinicians and public health professionals and naming just a few would be committing gross injustice to the hundreds of unsung heroes who have fought equally valiantly. And all this happened in a year already dedicated to nurses and midwives, who deserve our utmost gratitude.

In the second phase of this pandemic, based on the lessons learnt, we must remain mindful of the importance of uninterrupted provision of all our priority interventions including those for maternal, neonatal and child health including childhood immunization, eradication of polio, and control and elimination of Tuberculosis, HIV/AIDS, Malaria, Hepatitis B&C, nutrition stabilization, and controlling noncommunicable diseases, while accelerating our march towards universal health coverage leaving no one behind. Time is not on our side as we already need a significantly enhanced level of effort to achieve our targets. It stands to reason that any further delays will further diminish our chances to success in attaining the goals that have thus far eluded us.

The world first learnt about the human immunodeficiency virus or HIV during the early eighties and its associated disease AIDS literally began as one shrouded in stigma and discrimination. In 1985 AIDS killed that master movie actor of our times Rock Hudson serving as a universal wake-up call. However, it was not until 1988 when the US President Ronald Reagan, well into the end of his second term, authorized his Surgeon General C. Everett Koop to write to every American household on his behalf concerning the preventive measures relating to this deadly disease. The step was unprecedented in the annals of communicable disease control and also signified the victory of public health over senseless stigma and false prejudices at a time when not enough was known either about the virus or the disease it caused.

Today close to 40 million people are living with HIV (PLHIV) further fueling the TB epidemic and over 33 million persons dead due to the virus so far. The development of a life prolonging anti-retroviral therapy (ART) was a dramatic advance that helps people achieve favorable outcomes if the treatment is initiated at an early stage following HIV diagnosis. However, the challenge remains in achieving universal access to ART for PLHIV. Globally, TB remains the leading cause of death among PLHIV, accounting for a third of AIDS-related deaths.

Closer to home in Pakistan, UNAIDS estimates that there are 190,000 persons living with HIV  in the country, over 53,000 of which are women. Our country also follows the global 90–90–90 targets which expect that as soon as practicable, 90% of people living with HIV know their HIV status, 90% of those who know their HIV-positive status will be on ARTs while 90% of the latter will have suppressed their viral loads. However, as of 2018 in Pakistan only 14% of people living with HIV knew their status, while only 10% of people living with HIV were on treatment. Ten per cent of pregnant women living with HIV accessed antiretroviral medicine to prevent transmission of the virus to their baby, while the percentage of HIV-exposed infants tested for HIV before eight weeks of age stood at 2%. The knowledge about the modes of transmission of the disease is very low and the risk of TB-HIV co-infection even lower. Currently, UNAIDS estimates that 21% of the PLHIV are aware of their status, while 24,000 people are receiving ARTs in Pakistan, with the generous support from The Global Fund.

While efforts to control AIDS in Pakistan have centered around a few high-risk groups, regarded as the bridge for the virus entering the general population, as evinced in several countries of the world. In Pakistan these groups mostly include commercial (predominantly female) sex workers, men having sex with men (MSM), Men having sex with Women (MSW), transgenders and people who inject drugs (PWID). Concentrated epidemics have been identified in these groups periodically by the national or provincial programs. The problems encountered by the latter are compounded by the fact that they mostly come under the preview of some laws and legally do not exist! Therefore, the percentage of such persons accessed and educated remains low despite civil society engagement. However, some recent experiences have been a matter of great and added concern.

Writing on this very subject in this newspaper on December 1, 2018, I noted inter-alia that: “[t]he federal and provincial programs for HIV/AIDS control started way back in 1994, will be standalone as a health intervention initiated in Pakistan’s Health Sector against a perceived threat in the future; normally the action comes in the face of a growing challenge. This single fact is responsible for containing the threat to the present low level of around 0.05-0.07 percent prevalence in the country. Yet we also have to be mindful of the potential hazard associated with the slightest degree of neglect, that could lead to a major epidemic in less than no time and reverse all the gains achieved over the past quarter century.”

Five months later, Pakistan was shaken up by the Ratodero episode. As The Lancet of July 1, 2019 described it, “In April, 2019, an HIV outbreak was reported in the town of Ratodero in Larkana district, Sindh province, Pakistan. The outbreak was highlighted when 15 children with persistent fever were sent for HIV testing at a government-contracted facility and all were found to be infected. Blood reports were confirmed by another laboratory after referral from the Sindh HIV/AIDS Control Programme. These astonishing results panicked the health administration because the chance of perinatal transmission was already ruled out in these children. HIV screening of residents of affected areas revealed more alarming results.”

Programmatic data indicated that as of 15 July 2019, 31,239 people had been screened of which 930 (3%) were found positive for HIV, 82% of which (763) were were below 16 years old, while 70% (604) were aged 5 years or below. Investigations revealed that unsafe injection practices were the most likely reason for the large number of HIV infections among children. This was also seen as a spill-over of the well-established concentrated HIV sub-epidemic in key populations in Larkana. This also had severe implications for other blood borne infections such as hepatitis B and C, which have already reached alarming proportions.

The Lancet appreciated the HIV preventive steps taken by governmental agencies in collaboration with the UN agencies towards ensuring the availability of ART for patients and supporting technical investigations and enhancing public awareness. The journal, however, points out the need for significantly expanding treatment facilities, taking strict legal action against individuals who impersonate health-care providers and focusing on other areas in the Punjab province where similar outbreaks occurred in January, 2019. We also need to bear in mind that around 20,000 new infections are occurring every year, which could double over the next five years unless the epidemic is contained.

The working of the national and provincial programs requires a more detailed analysis to identify the barriers that result in sub-optimal outcomes. First and foremost is the issue of domestic funding of not just HIV/AIDS but the entire TB, HIV and Malaria, which is quite lopsided with the principal funding coming from The Global Fund and the major proportion of planned activities going unfunded due to inadequate contributions from the government sector. This also denotes a mismatch between the official pronouncements from the top health leadership and concrete budgetary allocations, warranting the need for bridging the gap between public policy and practice.

This has also resulted in insufficient government ownership of the programs with a generally weak and fragmented national monitoring and evaluation system with parallel systems lacking in overall stewardship. As a result, MIS systems fail to track progress against national and provincial strategy targets. Other barriers include a low prevention and testing programme coverage, treatment access, initiation and adherence, high treatment attrition rates and lack of strategic program oversight.

The recently drafted Pakistan AIDS Strategy (2021-2025)  envisages a number of steps that include increased testing coverage and reduced risk behaviours among key populations and their partners. In doing so the coverage of PWIDs will be raised from 29% to 73%, MSM from 9% to 86%, MSWs from 23% to 86%, transgenders from 27% to 86% and Female sex workers from 4% to 76%.  Other important strategies are to substantially increase ART initiation and retention, within key populations and their spouses/partners and children proportionally covered, creating an enabling environment for an effective and sustainable AIDS response, robust monitoring and evaluation and carrying out an Integrated Biological and Behavioural Surveillance survey that reveals certain sensitive behavioural data concerning high risk groups. The imperative of removing all stigma and discrimination attached to the disease warrant affirmative action at all levels of health services, enabling PLHIV to access care.

Meanwhile, winds of change are discernible as evinced by the energetic programmatic leadership and other aspects at the level of the Federal Government, which had created a Common Management Unit (CMU) since 2016 to integrate all matters relating to eliminating Tuberculosis, HIV/AIDS and Malaria from the country by 2030 as per its commitment to achieving SDG goals. Several other initiatives being taken in tandem that will strengthen these efforts such as attaining Universal Health Coverage by the year 2030. The Government of Pakistan has developed a Reform Plan by the Common Management Unit delineating the roles and responsibilities of the Federal and Provincial Governments with regard to these three diseases in the context of devolution.

The plan envisages that CMU will fulfil all its constitutionally federally mandated roles, while encouraging provincial governments to take up greater challenges and responsibilities with regard to financing and implementing the programs after their technical, managerial and financial capacity is significantly enhanced.

In order to concretize the plan in practical terms and rectify the funding imbalance, the Special Assistant to the Prime Minister for Health has advised developing a project document to access developmental budget to the tune of PKR 57 billion (roughly USD 350 million) for the next three years from July 2021-June 2024, with half of the cost borne by the Federal Government and the remaining half by all the provincial governments combined. This will ensure that provinces will allocate their resources to fill their strategy gaps leading to long term financial sustainability. The Parliamentary Secretary for Health has also been very keen to drive legislation that helps to address the barrier in health service delivery at all levels.

As per the Reform Plan and financing plan by the upcoming project document, there will be a sharp focus on strengthening of the CMU, enabling it to take up all its federal roles including policy/vision development, health legislation, health information, health security, enhancing technical support to provinces, inter-provincial and cross-border issues, implementation of International Health Regulations, disease surveillance backed up by the National Reference Laboratory, monitoring and evaluation, fulfilling international commitments, operational research. and providing oversight to programmatic implementation in the federally administered areas, while bringing about extreme transparency in utilization of all the domestic spending and grant money.

Recognizing the fact that there are several unfunded areas in the national and provincial strategies, the project document or PC-I proforma will finance the implementation of these areas including enhanced quantum of private and community sector engagement to bring about a significant dent in the disease burden of the three diseases.

The main areas under the project components include a) leadership and governance and other salary costs, b) enhancing technical expertise of the provinces, c) health information and health security, d) Integrated National Reference Laboratory, e) Research and Development, f) monitoring and evaluation, g) inter-provincial coordination, h) program implementation in all the provinces and federally administered areas encompassing cost of anti-TB medication and diagnosis, other logistics and transport costs, i) expanding public-private mix activities through civil society organizations, j) GF grant management, k) behavior communication change and social mobilization to remove stigma and discrimination, l) office maintenance, logistic costs, travel costs and m) contingencies. The areas of infection control and expanding ART coverage will also be addressed for the HIV component at federal and provincial. The PC-I is expected to be prepared soon, along with its implementation plans to be developed in consensus with all the provinces, partners and communities concerned through provincial or regional workshops, enabling it to be approved by all the relevant economic forums and beginning implementation by July 2021. United Nations agencies including UNAIDS, WHO, UNESCO, UNICEF and UNODC are expected to collaborate on technical issues as members of a coordination committee notified by the Ministry of National Health Services, Regulation, and Coordination (MoNHRSC);

The CMU will be an integral part of the Communicable Disease Control Programme (CDC) section within the MoNHRSC, and not work as a standalone structure. This arrangement will also enhance the role of the National Reference Laboratory based in the National Institute of Health for TB, HIV/AIDS and Malaria, and will be coordinating with other health entities such as the National Health Information and Resource Center, Pakistan Health Research Council, Directorate of Central Health Establishments, Health Services Academy/University and Safe Blood Transfusion Authority. Linkages will also be developed to harness support from programs offering social safety nets. This approach will also be useful in targeting social determinants of health acting as barriers to HIV, Malaria and TB care services .

In order to retain complete program ownership, the MoNHRSC and provincial Health Departments will provide funding for certain core/permanent positions for the three programs within the CMU, while some positions will continue to be financed by the Global Fund, according to some mutually agreed and equitable formula. As part of the federal mandate, a Technical Support Unit will be fully established within the CMU that will provide long-term support to provincial programs and partners in implementing programmatic interventions.  More importantly, both HIV/AIDS and Tuberculosis have to be regarded as social issues and not just health issues, requiring a multi-sectoral approach with involvement of all social sectors and safety nets.

The task is by no means easy but has to be achieved at all costs. Public health victories seldom come about by default and always require a concrete and deliberate effort. While health programs are putting in their concerted efforts for communicable diseases control, their pace of effort needs to gather greater momentum. Let us hope that governmental efforts at federal and provincial level together with United Nations’ agencies/funds, private health sector, other stakeholders with robust civil society engagement prove to be enough for the task at hand, enabling to offer our children a safer future devoid of deadly communicable diseases such as HIV/AIDS, Tuberculosis and Malaria. This is an opportunity we cannot afford to miss!

The writer is a senior public health specialist of Pakistan and can be reached at gnkaziumkc@gmail.com