巴基斯坦信德省的愛滋病危機：冰山的頂端
資料來源：刺胳針感染症醫學期刊，www.thelancet.com/infection Vol 19 July 2019，
財團法人台灣紅絲帶基金會編譯
從2010年到2017年巴基斯坦的愛滋病例總體增加比率為45％，年發生數為20,000。 據巴基斯坦國家愛滋病控制計畫（NACP）報導，在全國範圍內有近165,000人生活在愛滋病毒感染狀態中，其中只有24,331人（15％）知道他們的狀況。在2019年，迄今為止只有17,149名在NACP計畫註冊之患者已經接受了抗反轉錄病毒治療（ART）。在該國的農村地區因缺乏意識和文盲，很有可能對愛滋病控制計畫更產生了不利影響。
在2019年4月，巴基斯坦信德省Larkana區的Ratodero鎮據報導爆發了愛滋病毒流行。當1 5個孩子持續發燒被到送到政府合約的愛滋病毒檢測機構進行檢測後，且所有人都被發現血液感染了病毒時，爆發流行亦被突顯出來。血液檢驗報告在經由信德省愛滋病毒/愛滋病控制計畫轉介到另一個實驗室並經證實之後，由於這些孩子於產期前後可能感染的機會已經被排除了，而這些令人驚訝的結果讓衛生當局驚慌失措。
受影響地區居民的愛滋病毒篩查後顯示更加警示的結果。在篩查超過4,100人後確定了157例HIV陽性病例。測試呈陽性者當中，30人為成人並有127個孩子。衛生部和有關官員做了調查探究其爆發原因，並確認了重複使用受污染的拋棄式注射器為可能的一個因素。注射器曾被冒稱醫生的人多次重覆使用過。巴基斯坦政府與聯合國的合作，已經採取一些明顯的步驟朝向愛滋病預防，如確保患者治療的可獲性和幫助專門的愛滋病調查，但更重要的是預防也和一般民眾之意識有關。全國性的公眾意識活動，針對風險因素的公眾演講，和普遍的篩檢營等都應該被組織起來，特別是在偏遠地區，以幫助早期發現指標案例，從而防止進一步的流行。還有，急需要擴展國家愛滋病控制計畫( NACP ) ，因為抗反轉錄病毒藥劑治療( ART )目前在全國僅有24, 000名患者透過35個愛滋病治療中心能夠獲得治療。
只有七個愛滋病治療中心在信德省，且都存在於主要城市中，這可能會導致無法遵從醫囑規則服藥，因為抗病毒藥劑治療其可獲性之容易與否很可能會與醫療的順從性有關鍵的作用。另外，法律相關之執法機構應該針對違法冒稱之醫療保健提供者採取嚴格的法律行動，因為他們的不法行為，被認為是巴基斯坦在過去幾年裡，潛藏在多次的愛滋病流行背後的一個主要原因。
像此次這樣的愛滋病流行在巴基斯坦並不是新的疫情– 類似的爆發流行在2019年1月便曾發生在旁遮普邦省。在農村於短期間內再次地爆發流行疫情，應該提醒採取一些主動之行動，以避免將來再次發生類似之危機。
HIV crisis in Sindh, Pakistan: the tip of the iceberg
Pakistan has had a 45% overall increase in HIV cases from 2010 to 2017, with an annual incidence of 20, 000. According to Pakistan’s National AIDS Control Programme (NACP), nearly 165, 000 people are living with HIV nationwide, of whom only 24, 331 (15%) are aware of their condition. In 2019, so far only 17,149 patients registered with NACP have received antiretroviral treatment (ART). Poor awareness and illiteracy in rural areas of the country are likely to have adversely affected the AIDS control programme.
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. 157 HIV-positive cases were identified after screening of more than 4100 people. Among individuals who tested positive, 30 were adults and 127 were children.3 The Health Ministry and concerned officials did an inquiry to explore the cause of the outbreak and identified the reusing of contaminated disposable syringes as a possible factor. Syringes had been used multiple times by someone impersonating a doctor. The Pakistani Government, in collaboration with the UN, has taken some appreciable steps towards HIV prevention, such as ensuring the availability of treatment for patients and aiding specialised HIV investigations, but importantly prevention is also linked to awareness in the general population. Nationallevel awareness campaigns, public speaking regarding risks factors, and frequent screening camps should be organised, particularly in remote areas, to aid early detection of index cases, thereby preventing further epidemics. Also, an urgent expansion of NACP is needed because ART is currently available to only 24 000 patients nationwide through 35 HIV treatment hubs. Only seven HIV treatment centres exist in Sindh province, and all are in major cities, which probably leads to non-compliance since ease of availability of ART is likely to have a key role in adherence. In addition, law enforcement agencies should take strict legal action against individuals who impersonate health-care providers, since their malpractices are thought to be a primary reason behind various HIV epidemics in Pakistan in the past few years.
HIV epidemics like this are not new to Pakistan—a similar outbreak occurred in January, 2019, in Punjab province. This recurrence of rural epidemics within a short period of time should prompt initiatives to prevent such crises in the future.
I declare no competing interests.
Fizzah Arif
Gulshan-e-Iqbal, Karachi 75300, Pakistan.
www.thelancet.com/infection Vol 19 July 2019