資料來源：刺胳針傳染病醫學期刊，財團法人台灣紅絲帶基金會編譯，www.thelancet.com/infection Vol 19 July 2019

巴基斯坦的薩爾戈達爆發愛滋病毒流行

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「刺胳針傳染病醫學期刊」已收到幾封來自巴基斯坦關心愛滋病流行之衛生專業人員的信，疫情似乎源自於在偏僻的鄉村小鎮中，通常是不衛生和不受管制的醫療操作所致。 2019年3月，據Braira Wahid的報導，巴基斯坦旁遮普省Sargodha區所在地的一個村莊爆發了愛滋病毒流行，愛滋病毒盛行率在6個月內從1％上升到佔13％左右。經由對患者的訪談顯示他們中的許多人在測試病毒陽性之前，都被同一個無執照的從業者治療過。

隨後，我們收到了Fizzah Arif的一封信描述在巴基斯坦信德省Larkana地區爆發的愛滋病毒流行。疫情爆發首次於四月被報導，當時有15名持續發燒的孩子被發現感染了病毒，且從那之後由於其規模和受影響的以兒童為主，引起了國際的關注。針對爆發流行的回應立即展開，全國愛滋病控制計劃（NACP）開始了一項以篩檢為主的活動，已經有超過26 ,000人接受了愛滋病毒檢測。約有700個病例被確認，影響超過了600名兒童，其中大多數年齡小於5歲。在排除了母嬰傳播感染後幾乎所有案件，懷疑都朝向受污染的血液產品和醫療設備。結果，好幾百個未註冊的血庫和由無執照的從業員所經營的診所被關閉，並且一名註冊的兒科醫生因與100多名兒童疫情有關，被控因透過使用受污染的注射器傳播愛滋病毒而被捕。但是，隨著大多數感染源仍未詳加說明，以及這波流行的程度可能仍未知，由世衛組織協調的國際應急小組之任務是調查疫情。他們的報告正是在刺胳針傳染病醫學期刊已出版之後發布，將是對巴基斯坦當前的健康狀況的一個失敗的控訴。

2018年，聯合國兒童基金會的一份報告，將生於巴基斯坦列為世界上最危險的地方。眾多健康指標，特別是與健康指標有關母嬰健康狀況，巴基斯坦比處在南亞地區的其他地方更為糟糕。可預防的傳染病仍然是該國發病率和死亡率的主要原因；這種情況可歸因於許多複雜的社會、政治和結構上的因素導致不夠格的衛生狀態、不安全的飲用水，過度擁擠、低社經狀態和疫苗接種覆蓋率低。較低的健康素養並且因地域不同和性別差異而變化：來自該國2017-18人口統計與健康調查的估計顯示，在該國低至32％的女性和67％的男性曾經聽說過愛滋病毒/愛滋病，對該病的全面了解程度更分別地僅限於4％和10％。儘管巴基斯坦政府於1986 – 87年間發起了愛滋病毒/愛滋病的NACP計畫，一項預防和提高認知的計畫，這些調查結果仍然呈現。

在巴基斯坦與健康提供者（無論合法與否）有關的愛滋流行的相關報導，已經突顯出該國在血源性感染的負擔來源上並沒有受到重視，這些先前可能被歸因為該國有大量的靜脈注射藥癮者和性工作者其間的傳播。這些報告關注的有幾個原因。首先，這些報告指出在對愛滋病毒傳播的感染控制的過程和其機制方面，巴基斯坦的衛生工作者當中存有一個令人擔憂但有跡可尋的知識差距；其次，他們可以表明該國衛生系統監管上的嚴重失效，它允許人們在沒有適當的培訓和認證下，便自稱為醫生。第三，它們可能導致對衛生系統的恐懼和不信任，進一步加劇了國家的健康困境並使健康目標遙不可及。

在Larkana地區對愛滋病毒爆發流行的反應相當地迅速，並有各個國際機構和聯邦政府和省參與其中。一項針對兒童提供抗反轉錄病毒藥物（ART）治療的新診所已在Larkana成立，雖然這些目前可及的治療會持續多長的時間尚不清楚，在巴國境內ART的獲取通常是有限的。派駐在巴基斯坦的聯合國組織正在支持聯邦政府制定短期和長期的計劃，以確定和減輕疫情爆發的原因，包括去強化愛滋病醫療照護的連續性，促進健康教育，以及減少污名恥辱。但是，這場悲劇並不應該被用來去刺激行動；而現在至少巴基斯坦的衛生當局必須將其當作為變革的催化劑。

■剌胳針傳染病

HIV epidemics in Pakistan

The Lancet Infectious Diseases has received several letters from concerned health professionals in Pakistan about HIV epidemics that appear to have stemmed from unsanitary and unregulated medical practice, usually in isolated, rural towns. In March, 2019, Braira Wahid reported an outbreak of HIV in a single village in Sargodha district, Punjab province, Pakistan, where the prevalence of HIV infection increased from 1% to around 13% in 6 months. Interviews with patients revealed that many of them had been treated by the same unlicensed practitioner before testing positive for the virus.

Subsequently, we received a letter from Fizzah Arif describing an outbreak of HIV in Larkana district, Sindh province, Pakistan. The outbreak was first reported in April, when 15 children with persistent fever were found to be infected with the virus, and has since garnered international attention owing to its size and the preponderance of children affected. Responding immediately to the outbreak, the National AIDS Control Programme (NACP) began a major screening campaign that has seen more than 26 000 people tested for HIV. Around 700 cases were identified, affecting more than 600 children, most of whom are younger than 5 years. After ruling out mother-to-child transmission in almost all cases, suspicion turned to contaminated blood products and medical equipment. As a result, several hundred unregistered blood banks and clinics run by unlicensed practioners were shut down, and a registered paediatrician linked to more than 100 children in the outbreak was arrested on charges of spreading HIV through contaminated syringes. However, with the sources of most infections unaccounted for, and the extent of the epidemic likely unknown, an international response team coordinated by WHO was tasked with investigating the outbreak. Their report, due after The Lancet Infectious Diseases had gone to press, may be a damning indictment of the current health situation in Pakistan.

In 2018, a UNICEF report ranked Pakistan as the riskiest place to be born in the world. Numerous health indicators, particularly those related to maternal and child health, are worse in Pakistan than elsewhere in the south Asian region. Preventable communicable diseases remain a primary cause of morbidity and mortality in the country; a situation that can be attributed to many complex societal, political, and structural factors that lead to inadequate sanitation, unsafe drinking water, overcrowding, low socioeconomic status, and poor vaccination coverage. Health literacy is low and varies geographically and by sex: estimates from the country’s 2017–18 Demographic and Health Survey suggest that as little as 32% of women and 67% of men in the country had ever heard of HIV/AIDS, with comprehensive knowledge of the disease limited to 4% and 10%, respectively. These findings are despite the Pakistani Government launching the NACP, an HIV/AIDS prevention and awareness programme, in 1986–87.

The reports of HIV epidemics in Pakistan linked to health providers (legitimate or not) have highlighted a potentially unappreciated source of the burden of bloodborne infections in the country, which has previously been attributed to transmission among the country’s considerable population of injecting-drug users and sex workers. These reports are concerning for several reasons. First, they could indicate a worrying but potentially addressable knowledge gap in infection control processes and mechanisms of HIV transmission among health workers in Pakistan. Second, they could suggest a severe lapse in regulation of the country’s health system, which allows people without appropriate

training and certification to call themselves doctors. Third, they could lead to fear and mistrust of the health system, further exacerbating the country’s health woes and putting health targets out of reach.

   The response to the HIV outbreak in Larkana has been fairly swift, involving various international agencies and provincial and federal governments. A new antiretroviral treatment (ART) clinic for children has been established in Larkana, although how long these treatments will be available is unclear, with access to ART generally limited in the country. The UN in Pakistan is supporting the federal government to develop short-term and longterm plans for identifying and mitigating causes of the outbreak, including strengthening the continuum of care for HIV, promoting health education, and reducing stigma. However, it should not have taken this tragedy to spur action. The health authorities in Pakistan must at least now use it as a catalyst for change.

■ The Lancet Infectious Diseases