Peer reviewed / Observational study / People
- First scientific analysis of outbreak finds average age of children affected is 3 years
- One in three children yet to start treatment by end of study period
- First time exact figures available since media reports alerted local officials to outbreak in April 2019
- Results confirm likely main causes are reuse of contaminated needles and use of contaminated blood for transfusions
- Authors call for better regulation and training of health-care providers
The HIV outbreak in Pakistan is unprecedented in terms of the proportion of young children affected, mostly under 5-years-old. It represents a 54% increase in paediatric diagnoses over the past 13 years, according to an observational study of more than 30,000 people in the town of Ratodero, published in The Lancet Infectious Diseases journal.
The results, which are the first scientific report on the outbreak, appear to confirm observations by a government taskforce that HIV was mostly transmitted to children as a result of health care providers using contaminated needles and blood products. Of the 591 children registered for HIV care, 395 (67%) had started antiretroviral treatment by mid-July, due to an inadequate supply of drugs and a lack of trained staff.
"Pakistan has experienced a series of HIV outbreaks over the past two decades, but we've never before seen this many young children infected or so many health facilities involved," says Dr Fatima Mir from The Aga Khan University in Pakistan. "Use of syringes and needles is widespread and Pakistan has one of the highest rates of unsafe injections in the world. Health practitioners need to use intravenous treatment only when necessary, use needles only once, and screen blood for infections before using it for transfusions." 
Most people (70%) in Pakistan are served by the private health sector, which includes unregulated hospitals and doctors. Patients and carers have a strong preference for treatment via injections because they perceive oral treatments as less effective.
As well as highlighting measures to control infection, the authors propose urgent government priorities to help both prevent and treat paediatric HIV. For example, providing drugs to treat HIV and blood-borne viruses, training and regulation of health care providers, and improving surveillance of viruses in the population. They recommend research to better understand how the epidemic came about, for example how it may have spread from high-risk groups such as people who inject drugs (PWIDs) and sex workers to the general population. They suggest low condom usage and risky injection practices may have contributed. Such information could help improve management of HIV in both the province and nationally.
The outbreak was discovered in the town of Ratodero in April 2019 and the high proportion of paediatric cases was widely reported in the news media. In response, a government taskforce - supported by academic experts and UN agencies - visited private and public health facilities, where they observed needles being reused and blood products being used without screening for infections. This led to the closure of three blood banks, almost 300 clinics, and the Sindh Health Care Commission.
A screening camp was established at Tehsil Hospital in Ratodero to provide free voluntary HIV testing and counselling for all age groups, and large numbers of people attended. Between April 24, and July 15, 2019, 31,239 people were tested for HIV, and data were collected on their clinical history, such as previous injections, cannulations, blood transfusions, and parental HIV infection. For the current study, researchers reviewed the data generated, providing the first scientific analysis of the epidemic and of the response to it.
A total of 930 people tested positive for HIV, of whom 604 (79%) were 5 years old or younger, and 763 (82%) were younger than 16 years. Doctors had observed high numbers of paediatric diagnoses in their clinics, but this is the first time an analysis of the exact figures has become available. By the beginning of July, 591 children had been registered for HIV care. The average age was 3 years old, and 478 (81%) of the 591 children were 5 years old or younger. Before March 2019, only 1,423 children had registered for HIV care across the whole country since records began 13 years ago. The 763 new HIV cases in less than 12 weeks and in a single district represent a 54% increase in national figures (from 1,423 to 2,186).
The authors observed that more boys were affected than girls, comprising 61% (464/763) of children diagnosed with HIV and 64% (379/591) of children registered for HIV care. This study was unable to shed light on the why this might be.
Data was available for 453 of 763 children to suggest how they became infected. Most of the children (404/453, or 89%) reported multiple previous injections, usually to treat diarrhoea or respiratory tract infections. Multiple injections refer to treatment, rather than vaccinations. A smaller number of children (40/453 or 9%) had undergone blood transfusions, usually to treat iron deficiency anaemia, with four also treated for the blood disorder thalassaemia. 15 children reported having received neither multiple injections nor a blood transfusion. Of these, 12 of their mothers had an HIV test and all tested positive.
Several limitations to the study are highlighted by the authors. Media coverage of the outbreak focused on 14 infected children, which could have resulted in more children than adults being tested for HIV. In terms of pinpointing when children became infected and how needles and blood products became contaminated, this has been made harder because most of the children registered for care were found to be in an advanced stage of the disease.
Writing in a linked Comment, Professor Mark Cotton from Stellenbosch University, South Africa, says: "The most worrying aspect of the outbreak is the link with a breakdown in safe injection practice and poor management of donor blood. Of 16 billion injections administered every year globally, only 5% each are for immunisation and for contraception respectively. The majority (90%) are for therapy and often unnecessary, easily replaced with oral medicines."
NOTES TO EDITORS
This study did not receive any funding. It was conducted by researchers from Aga Khan University, Karachi; the Ministry of Health, Sindh; and the London School of Hygiene and Tropical Medicine.
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The Lancet Infectious Diseases