HIV Outbreak in Pakistani Children Likely Caused by Poor Infection-Control Practices

By Reuters Staff

January 08, 2020

NEW YORK (Reuters Health) - An HIV outbreak predominantly affecting children in Pakistan likely resulted from poor infection-control practices, researchers report.

The number of people in Pakistan living with HIV increased 127% between 2010 and 2017, but only about 2% of these cases were in children younger than 15 years. In April 2019, however, 46 children in Karachi with thalassemia and 14 children in Ratodero were diagnosed with HIV. Both cities are in the Sindh province of Pakistan.

Dr. Fatima Mir of Aga Khan University, in Karachi, and colleagues review the features of the outbreak and the government, academia and United Nations responses to the outbreak in their report in The Lancet Infectious Diseases.

Free voluntary HIV testing and counseling, beginning in April 2019 and still ongoing, identified 930 individuals with HIV, of whom 763 were children aged up to 15 years, including 604 who were aged 5 years and younger.

By July, 591 of these children (median age, 3 years) had registered for HIV care at the pediatric clinic at the district hospital established in response to the outbreak.

Most of these children (77%) had moderate to severe anemia, and 53% had a median weight-for-age 3.2 standard deviations below normal. Severe immunodeficiency was present in 15% of these children, and 80% had stage 3 or 4 HIV disease using WHO staging criteria.

Only 67% of infected children who registered for care commenced antiretroviral therapy, because of the unavailability of adequate drug supplies and trained staff.

"Alarmingly," as an editorial accompanying the report notes, only 11% of the 371 mothers were HIV-positive (for fathers, the number was 3%).

Most of the HIV-positive children (89%) had a history of multiple injections, and 9% had a history of blood transfusions (four with thalassemia and 36 with iron deficiency anemia).

Of the 15 children with neither blood transfusion nor multiple injections, 12 had mothers who were tested and all were HIV-positive.

"A need to invest in improvement of blood safety services and infection control and regulation of health care providers is urgent," the authors note.

"Epidemiological and phylogenetic studies are underway and will help to elucidate the evolution and propagation of this HIV outbreak," they add. "Importantly, epidemiological surveillance needs to be strengthened and involvement of communities should be a crucial component of the response if the HIV epidemic in Pakistan is to be controlled."

"The most worrying aspect of the outbreak is the link with a breakdown in safe injection practice and poor management of donor blood," write Dr. Mark F. Cotton of Stellenbosch University and Dr. Helena Rabie of Tygerberg Hospital, both in South Africa, in the editorial.

"The WHO has set a deadline of 2020 for transition to safety-engineered syringes that can only be used once," they explain. "These single use syringes are an essential component of the Sustainable Development Goals, established by the UN in 2012, to be reached by 2030. Until this target is reached, limiting injections to only those necessary, ensuring disposable needles and syringes are not reused and are safely disposed of, and improving access to appropriate oral medications are essential to prevent harm associated with health care."

Dr. Mir did not respond to a request for comments.

SOURCE: and Lancet Infectious Diseases, online December 19, 2019.