In the 40 years since HIV/AIDS emerged as a global health crisis, HIV/AIDS continues to affect millions of people around the world. Despite incredible advances in medical care and treatment, there are still an estimated 36.9 million people living with HIV in 2017, 1.8 million of them children. HIV/AIDS affects not only individuals, but also their families, communities, and countries. Low and middle-income countries bear the largest burden in the current HIV/AIDS epidemic. These countries often have limited resources to test and treat people living with HIV and lack the infrastructure or financial means to build additional resources.

The current HIV/AIDS outbreak in Sindh, Pakistan is one example of this issue. Of the 150,000 people living with HIV in Pakistan, over half live in Sindh. In the past month (April 2019), over 600 people have tested positive for HIV in Sindh, nearly 500 of these children and 90 pregnant women. These new diagnoses are stretching the already limited HIV treatment options. Additionally, without help to identify and eliminate the unsafe medical practices that caused the current outbreak, future outbreaks are likely to occur. Efforts to train physicians to treat HIV, increase access to HIV testing and treatment, and improve the sanitation of medical practices are critical.

The Providence/Boston Center for AIDS Research in collaboration with the Jinnah Sindh Medical University Alumni Association of North American (JSMUAANA), the Jinnah Sindh Medical University (JSMU), Association of Physicians of Pakistani Descent of North America (APPNA), and the Association of Pakistani Physicians of New England (APPNE) have developed the HIV/AIDS Communications Project Part I: HIV in Sindh, Pakistan.  This project aims to teach and train healthcare providers on HIV disease to reduce stigma and increase awareness about HIV, and develop HIV treatment protocols given the limited resources available in Pakistan.

HIV in Pakistan Project Progress Report

The country of Pakistan has a history dating back thousands of years but was only established as a sovereign state 14^th August 1947. The capital is Islamabad and the country consists of six regions: Khyber Pakhtunkhwa, FATA, Punjab, Baluchistan, Sindh, and Islamabad Capital Territory (ICT). A census conducted by the Pakistan Bureau of Statistics in 2017 concluded that Pakistan has a total population of about 207.7 million people.

The largest province, Punjab, hosts a population of about 110.0 million people followed by Sindh at 47.9 million, Khyber Pakhtunkhwa at 30.5 million, Baluchistan at 12.3 million, FATA at 5.0 million, and Islamabad at 2.0 million. 

Fizza Gillani, PhD

Rizwan Naeem, MD

Syed Iftikhar Hussain, MD

Aziz Soomro, MD

Irfan Sulemen, MD

Farooq Soomro, MD

A team of medical professionals (representing the following organizations: Providence/Boston CFAR, JSMU, JSMUAANA, APPNA and APPNE), collaborated to provide HIV disease information to the medical community in Pakistan in response to the recent HIV outbreak in Sindh, Pakistan. A total of six webinars were conducted weekly from May 19, 2019 to June 23, 2019 on topics ranging from HIV testing and stigma to caring for co-infected patients. Below are summaries for each of the webinars. 

Webinar Series PDF

Webinar #1: HIV Disease: Myths and Facts

Date & Time: May 19^th, 2019, 12:00-1:30 PM EDT

Host & Speaker: Fizza S. Gillani, PhD

The first webinar of this series served as an introduction to the HIV disease for the medical community in Sindh. Key features discussed during the webinar included:

• HIV definition and disease progression
• Various modes of HIV transmission in general and those specific to Pakistan
• Myths and facts about HIV disease to reduce HIV stigma in Pakistan
• The importance of providing effective provider- patient encounters

The webinar was attended by medical school faculty, medical students, physicians, and health administrators from the Sindh Province, Pakistan. Concerns raised by the audience included: the unavailability of diagnostic equipment across the interior Sindh region, limited availability of HIV drugs, unethical practices of blood transfusion, re-using of syringes and lack of sufficient resources to address the HIV outbreak.

Webinar #2:  HIV Testing, Stigma and Patient- Provider Communication

Date & Time: May 26^th, 2019, 12:00-1:30 PM EDT

Guest Speaker: Phillip Chan, MD

Webinar #2 included information on the importance of establishing and sustaining an HIV testing system, one that would ensure early treatment and normal life expectancy, prior to dealing with the HIV outbreak. The following key features were discussed during this webinar:

• Different types of HIV tests
• HIV tests and treatment available in Sindh, Pakistan
• HIV diagnostic tests for newborns and infants
• How to address HIV outbreak
• How to address HIV Stigma specific to Pakistan

Participants of this webinar, representing members of the healthcare community in Sindh, Pakistan, raised numerous concerns during the discussion, such as the effectiveness of different HIV diagnostic tests in newborns, different HIV drug regimen therapies and the long-term side effects of HIV therapy.

Webinar #3: The HIV Care Cascade: An Example from Rhode Island

Date & Time: June 2^nd, 2019, 12:00-1:30 PM EDT

Guest Speaker: Joseph M. Garland, MD

The third webinar in this series included information about the HIV-Care Continuum, a treatment cascade which frames the treatment of HIV with the goal of viral suppression, and featured the following key points:

• The three components of the HIV-Care Continuum
• UNAIDS’ 90-90-90 campaign globally and in Rhode Island
• Necessity for educating patients and family members about HIV

During the discussion portion of this webinar, participants raised questions about the average cost of treating HIV in the U.S., standard precautions to follow in HIV clinics, and application of the 90-90-90 model in Pakistan, living at home with HIV infected person, training of medical staff, HIV post exposure prophylaxis guidelines, and poor health insurance system in Pakistan.

Webinar #4: Preventing Mother-to-Child HIV Transmission and Caring for Infected Infants & Children

Date & Time: June 9^th, 2019, 12:00-1:30 PM EDT

Guest Speaker: Susan Cu-Uvin, MD; Jerome Larkin, MD; Sabina Holland, MD

The fourth webinar in this series provides comprehensive knowledge about the presentation of HIV in children and the prevention of mother-to-child HIV transmission.  Speakers discussed the following key features during this webinar:

• Acute HIV infection in children and adolescents
• Clinical presentations of HIV in children
• Life-threatening opportunistic infections in children with HIV
• Management of HIV infection in children in resource-limited countries
• Prevention of mother-to-child HIV transmission

During the discussion portion of this webinar, participants (consisting mainly of medical staff and students from Sindh, Pakistan) asked questions on how to manage side effects of ARV therapy in children, the monitoring of HIV medicine toxicity in children, the best modes of delivery for HIV positive mothers and concerns about performing invasive procedures on HIV positive pregnant women.

Webinar #5: Caring for Co-Infected Patients (HIV-TB, HIV-HEP C, HIV-HEP B)

Date & Time: June 16^th, 2019; 12:00 – 1:30 EDT

Guest Speaker: Martha Sanchez, MD; Natasha Rybak, MD

Webinar 5 provided a comprehensive understanding of HIV co-infections with the following key features:

• The similarity between modes of transmission for HIV, Hepatitis B and Hepatitis C
• HIV-HEP B presentation, prevalence, diagnosis, and treatment
• HIV-HEP C presentation, diagnosis, and treatment
• HIV-TB presentation, diagnosis, and treatment for HIV infected children
• Importance of open communications between healthcare providers and patients about the disease.

Participants in this webinar raised concerns about managing infants with HIV co-infections, management of an HIV positive children with complications of TB, and the interaction of various drugs for co-infected children.  

Webinar #6: Fostering Hope: The Role of Mental Health Care in HIV Treatment from Start to Finish

Date & Time: June 23^rd, 2019; 12:00 – 1:30 EDT

Guest Speaker: Jamie Kenney, PhD; Aziz Soomro, MD

The sixth and final webinar in this series discussed the association between mental health care and HIV infection and treatment. Speakers addressed the adverse effects of antiretroviral therapy on patients’ quality of sleep, stress levels, and mental health, which can affect patients’ compliance towards HIV treatment. Key features discussed during this webinar included:

• Interventions prior to testing for HIV to address fears, social practices and beliefs
• Post-testing intervention and counseling
• Incorporation of psychological evaluations at each HIV appointment to prevent emergence of mental health symptoms
• Maintaining communication between healthcare providers and patients about HIV disease progression

Attendees of this webinar discuss the limited availability of facilities for pre- and post-testing counseling in Pakistan. Discussion involved raising awareness of mental health issues associated with HIV infection to doctors, nurses, and educators who encounter HIV infected patients. The goal of providers should be to instill hope into patients which will ultimately improve treatment compliance, decrease suffering, and improve patients’ quality of life.