Webinar 16: Building HIV Services Capacity in Pakistan: An Innovative Approach - Nov 7, 2022

The main focus of this webinar is the outlining of a proposal that addresses the HIV situation in Pakistan. The idea behind this proposal is to improve the quality of care regarding HIV cases. An example of a successful HIV treatment program from the United States is mentioned and serves as a model for the proposal. Three goals are held in mind for this project: assess HIV care; ensure proper treatment and support; and create integrated HIV care programs. The main idea of the "Build Capacity: Adopt an ART Center'' Project is to link medical colleges with local ART centers. The roles and benefits for the medical colleges, ART centers, and HIV Committee members (and others) are outlined. Finally, each party is given a series of future steps towards the implementation of this project.

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Webinar 15: Current HIV Treatment and Care Delivery Model in Baluchistan - Sep 18, 2022

In this webinar, Pakistan's approach to HIV is discussed with emphasis given to the current situation in the province of Baluchistan, Taking Pakistan as a whole, only 50,000 of 240,000 people are aware of their positive HIV status. The core issue is the provincial structure of Pakistan, which divides up information and treatment between the various provinces. This results in certain provinces declining to support or help the HIV response. Baluchistan specifically does not even focus on treating common diseases, and so HIV treatment is behind other parts of the country. In Baluchistan, the Quetta district has around 48% of the province's HIV cases, and other statistics are also discussed. There are a total of two ART centers in the province, with 6 more being built.

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Webinar 14: Iatrogenic transmission of HIV - poorly regulated transfusion of blood products in Pakistan - August 21st 2022

In this webinar, issues with blood screening and transfusion practices within the context of HIV are first discussed. In Pakistan, there is a lack of pre-donation screening for disease, which allows for them to be transmitted via transfusion. Blood transfusion reactions and grouping are also not documented properly. While Pakistan's blood bank system has been reformed, reforms have begun to stagnate recently and there is a risk for the blood bank system to completely fall back to its unsafe practices. Finally, a testing recommendation for screening blood donors is recommended in order to reduce HIV transmission.

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Webinar 13: Iatrogenic Transmission of HIV – Unsafe Reuse of Needles and Syringes in Pakistan – A Public Health Crisis - 7/31/2022 

This webinar describes the history of reported HIV outbreaks in Pakistan, the sheer volume of HIV-positive people (PLHIV) in Pakistan who are unaware of their HIV status, and the role of unsafe injection practices in fueling the HIV epidemic. While there has been significant improvement in safe injection practices globally since 2011, unsafe injections in Pakistan did not improve at the same rate. While approximately 1.5 billion syringes are being used in Pakistan each year, the current manufacturing capacity in Pakistan is less than 600 million syringes; this discrepancy results in syringe reuse, which is a major cause of HIV transmission in Pakistan. Improving injection practices in Pakistan requires a multifaceted response, including empowering the community to question the need for injections and instituting the use of reuse prevention syringes (RUP) in the therapeutic sector.

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Webinar 1: HIV Disease: Myths and Facts - 5/23/2021 

This webinar describes the ongoing epidemic in Pakistan and the initiatives of the APPNA MERIT HIV committee in raising awareness about HIV in Pakistan, which include collaborating with local healthcare institutions in Pakistan to help increase awareness about the HIV/AIDS disease. These activities aim to empower providers, patients, and communities with accurate knowledge about the disease, while  decreasing stigma surrounding routine testing and HIV diagnoses. There is often miscommunication around how HIV is spread, and the largest barrier to controlling the HIV epidemic in Pakistan has been denial and stigma. Increasing access to accurate education about HIV, normalizing testing for HIV, and encouraging open and informative conversations in Pakistan would make a large difference in transmission control.

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Webinar 2: HIV Testing, stigma, patient-provider
communication, and the HIV Care Cascade – 5/30/2021

This webinar describes the need for increased awareness about the HIV disease, destigmatization, normalization of routine testing, and improvements in patient-provider communication to address the HIV epidemic in Pakistan. Current challenges in Pakistan to combat this epidemic include linking patients to treatment, retaining patients in care, managing data, and identifying donor funding. In addition, further efforts are needed to reach hidden key populations. By monitoring and improving these efforts, the public health community in Pakistan can help to combat the stigma and discrimination related to the HIV disease, ultimately leading to increased screening and treatment outcomes for HIV throughout Pakistan. 

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Webinar 3: HIV Clinical Presentations and Treatment Options – 06/06/2021

This webinar identifies the HIV/AIDS presentation and describes the traditional, misinformed, and well-informed approaches to diagnosis. There is significant stigma around HIV testing and diagnosis, both of which have acted as barriers for prevention of further transmission. Primary HIV infections often go undiagnosed because there is not a high degree of clinical suspicion. Further, there are constraints with diagnosing patients and limited availability of treatment. 

Clinical intervention can be managed at the primary care level and should include routine labs, ART clinic referrals, and counseling. Transmission reduction proposals including needle exchange programs, increased testing, and post-exposure prophylaxis should be introduced to prevent further spread of the concentrated epidemic.

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Webinar 4: HIV/HCV Co-infections, Clinical
Presentations and Treatment Options – 06/13/2021

This webinar outlines and describes the prevalence and features of HIV and Hepatitis C coinfection. Pakistan has one of the highest Hepatitis C infection levels worldwide, with many cases originating from healthcare-acquired transmission. Despite the availability of generic direct-acting antivirals and reduced treatment costs, the prevalence of Hepatitis C remains persistent, with no evidence of declining prevalence. There is a large gap between infection and treatment, with a lot of people unaware of their Hepatitis C status. Early intervention and treatment are important in co-infected patients because HIV is independently associated with Hepatitis C progression. Patients with coinfection require dual therapy, which includes many guidelines to prevent drug interactions and contraindications. Encouraging collaboration between specialists as well as training family physicians, simplifying guidelines by adapting them to local conditions, and empowering general practitioners to approach testing and treatment in an unbiased manner will help to promote a national movement to encourage treatment and prevent transmission for HIV and Hepatitis C coinfection.

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Webinar 5: HIV/TB Co-infections, Clinical Presentations and Treatment Options – 06/20/2021

Tuberculosis and HIV requires prompt management and treatment to prevent further transmission and minimize the development of opportunistic infections. It is especially important that anybody diagnosed with Tuberculosis should be tested for HIV, and vice versa. For mono infection with Tuberculosis, treatment is straightforward and should be started immediately to prevent spread. In patients with Tuberculosis and HIV co-infection, pharmacotherapy options are reduced. The NRTIs (nucleoside/nucleotide reverse transcription inhibitors) do not have significant interactions and may be used for treatment. 

Clinicians must assess the most appropriate available therapy for their patient, as well as any necessary dose adjustments. HIV counseling and prophylactic treatment, as well as procedures for infection control, should be implemented. Ensuring patients have access to treatment and medication as well as a supportive healthcare staff can help to decrease the stigma behind HIV testing, and implementing more frequent Tuberculosis testing when appropriate will decrease the incidence of co-infection. 

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Webinar 6: Caring for pregnant women with HIV disease and preventing HIV Transmissions - 6/27/2021

Education and the implementation of standard practices to help prevent and reduce maternal transmission of HIV to infants has been an ongoing topic of discussion. HIV transmission from mother to infant generally occurs during labor, delivery, and subsequent breastfeeding. Key prevention tactics include universal HIV testing for all pregnant women and the implementation of antiretroviral therapy and adherence to therapy after diagnosis. The Dolutegravir-based regimen is recommended as the preferred first-line treatment for people living with HIV. There is very low evidence of neural tube defects for women and adolescent girls of childbearing potential who begin therapy. For healthcare workers who are working with HIV positive women for the duration of their pregnancy, it is extremely important that they receive training on infection control, occupational post exposure prophylaxis policies, and the importance of testing and treatment with emphasis on decreasing healthcare stigma against the disease.

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Webinar 7: Lifelong Care of Infants and Children Living with HIV – 7/18/2021

This webinar describes HIV infections and common clinical presentations of HIV in children, developmental effects, and pediatric HIV care in Pakistan. Though potentially preventable, most children are infected via mother-to-child transmission; these infections are compounded by poverty and challenges in access to healthcare, lack of HIV awareness, and limiting testing availability. HIV in children can lead to development delays, such as persistent weight loss, impaired brain growth, and/or motor defects. In Pakistan, 7 out of 50 ART centers are dedicated to pediatric care, while the remaining centers  treat both adults and children. HIV medicine and diagnostic tests are provided free of charge in all pediatric ART centers. Regardless of this, challenges persist: there are very few Pediatric Infectious Disease Physicians in Pakistan, proper linkage between pediatric and adult ART centers do not exist, and accessing HIV children’s services can be challenging given remote locations. In the future, there is a need to expand pediatric HIV centers and care services as well as to extend medication and other services in highly burdened districts to care for HIV positive children in Pakistan. 

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Webinar 8: Improving Quality of Care and HIV Education in Pakistan - A Brainstorming Session – 8/29/2021

Improving the quality of care and educating medical personnel and the general public about HIV is critical to addressing the current state of HIV in Pakistan. In this webinar, speakers and participants reflected on lessons learned from the previous six webinars delivered in 2021 and methods to improve HIV education and care in Pakistan moving forward. In general, webinar hosts and participants agreed that an increase in routine testing, implementing mandatory HIV courses in medical school, and increasing awareness about the disease in general were critical steps to addressing Pakistan’s HIV epidemic. Additionally, an interdisciplinary approach to health care more generally, such as developing an understanding of health care as medical sociology beyond just physician-patient relationships, would also help address health care challenges in Pakistan.

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Webinar 9: Sexually Transmitted Diseases STDs and HIV – 9/29/2021

This webinar describes important information on STI prevention, recommended treatments for specific STIs, and the relationship between most STIs and HIV. The Centers for Disease Control and Prevention (CDC) recommends the ‘Five P’ approach to STI discussions, involving dialogue on: Partners, Practices, Protection (i.e., condoms), Past history, and Pregnancy. Having any STI significantly increases one’s risk of acquiring HIV infection. In Pakistan, the most common STIs include gonorrhea, syphilis, chlamydia, HIV, fungal candidiasis, and trichomonas. Due to stigma, many individuals attempt to hide all signs and symptoms of STIs. In order to combat stigma and prevent STIs in Pakistan,  It is critical that STI education is implemented for politicians, religious leaders, students, and teachers, covering topics such as sexual behavior, mental health issues, and drug abuse in order to reduce disease prevalence. 

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Webinar 10: HIV Disease Among the Key Populations in Pakistan Part 1 – 10/24/2021

In Pakistan, there is significant stigma surrounding the HIV Disease and Key Populations (KP), including Pakistan’s Transgender population. Stigma and discrimination towards People Living with HIV (PLHIV) in Pakistan is pervasive, with fear and limited understanding of HIV transmission exacerbating this issue. Stigma is harmful to Pakistan’s health practice, families, and communities, and affects the ability for PLHIV to secure employment opportunities and live with dignity. In order to address these issues, Pakistan must ensure that the right to employment for PLHIV/KP is incorporated as an advocacy and human rights issue. Additionally, research institutions should undertake research to find evidence on employment-related stigma and discrimination so that targeted intervention strategies can be devised. Also, encouraging businesses and labor leaders to champion HIV anti-discrimination measures, deliver HIV education in work settings, and adopt other similar measures can help support the employment of PLHIV in Pakistan.

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Webinar 11: HIV Disease Among the Key Population in Pakistan Part 2 – 11/21/2021

This webinar describes the HIV situation for Injection Drug Users (IDUs) in Pakistan. Specifically in  Balochistan, two HIV/AIDS Centers provide HIV treatment to all registered patients free of cost, including IDUs. CoPCs (Continuum of Prevention and Care Services), funded by the Global Fund,  were established in 2014 to provide comprehensive services to IDUs in Pakistan’s 30 districts. However, challenges for addressing HIV infection in IDUs remain, including the need for new syringes/needles, a limited budget for basic medical care, a need for increased detoxification and rehabilitation centers, and a need for general social services to support IDUs. The Dost Foundation in Pakistan provides services for IDUs, serving a population of approximately 4.4 million drug users in KPK/FATA and adjoined Punjab districts. The Dost Foundation focuses on drug demand reduction, HIV prevention and care, human rights, human resource development, and community development. Organizations such as the Dost Foundation can provide vital support to the public health sector in Pakistan and address the growing HIV epidemic. 

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Webinar 12: Vision for HIV in Pakistan for 2022 – 12/19/2021

An update on the HIV Awareness, Prevention, and Education Project in Pakistan Report was published on World AIDS Day on December 1, 2021. This webinar described several key themes from the World AIDS Day report. These included: (1) Treatment as Prevention and measurement of Key Performance indicators to understand the percentage of patients who are newly diagnosed with HIV, those who are on ART, those who are virologically suppressed, and those who have died from HIV/AIDS-related deaths; (2) the Knowledge, Attitude, and Practice Gap, describing how HIV transmission is no longer confined to Key Populations, the general population is becoming infected due to unregulated use of contaminated needs and unscreened blood products, and discrimination and stigma is affecting HIV management and treatment adherence; and (3) Infection Prevention and Control, whereby external teams began training healthcare staff and managing treatment activities after the initial HIV outbreak in Pakistan. These trainings and management were not implemented in Pakistan's internal structures, and therefore, have not been fully adopted into Pakistan’s HIV prevention practices. Moving forward, these key themes must be emphasized as tools for preventing future HIV transmission and curbing the evolving HIV epidemic in Pakistan. 

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In April 2019, an HIV outbreak affecting primarily children in Larkana, Sindh, Pakistan left local healthcare providers overwhelmed and in shock; these providers required extensive knowledge to address the outbreak. Dr. Gillani was contacted by Larkana's healthcare providers to provide training and HIV education. In response, she designed and deployed this project, inviting her colleagues at Lifespan/Tufts/Brown CFAR to join. This project, academic in nature, was geared towards creating an educational campaign to reduce stigma and increase awareness about HIV/AIDS by empowering healthcare professionals with the latest knowledge about HIV in the affected area.

Webinar 1: HIV Disease: Myths and Facts
Date & Time: May 19, 2019, 12:00-1:30 PM EDT
Host & Speaker: Fizza S. Gillani, PhD

This webinar introduced details about the HIV disease to the medical community in Sindh. Key topics discussed include:

• 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 in Pakistan. Concerns raised by the audience included: the lack of availability of diagnostic equipment across the interior Sindh region, limited availability of HIV drugs, unethical practices of blood transfusion, re-use of syringes and lack of sufficient resources to address the province’s 2019 HIV outbreak.

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Webinar 2:  HIV Testing, Stigma and Patient- Provider Communication
Date & Time: May 26, 2019, 12:00-1:30 PM EDT
Guest Speaker: Phillip Chan, MD

This webinar provided information on the importance of establishing and sustaining an HIV testing system, one that will ensure early treatment and normal life expectancy, prior to dealing with an HIV outbreak. The following topics were discussed:

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

Webinar participants, 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.

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Webinar 3: The HIV Care Cascade: An Example from Rhode Island
Date & Time: June 2, 2019, 12:00-1:30 PM EDT
Guest Speaker: Joseph M. Garland, MD

This webinar provided 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
• The importance of educating patients and family members about HIV

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. The discussion also included information about living at home with an HIV infected person, training medical staff, HIV post exposure prophylaxis guidelines, and the health insurance system in Pakistan.

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Webinar 4: Preventing Mother-to-Child HIV Transmission and Caring for Infected Infants & Children
Date & Time: June 9, 2019, 12:00-1:30 PM EDT
Guest Speaker: Susan Cu-Uvin, MD; Jerome Larkin, MD; Sabina Holland, MD

This webinar provided 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

Webinar participants, including 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.

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Webinar 5: Caring for Co-Infected Patients (HIV-TB, HIV-HEP C, HIV-HEP B)
Date & Time: June 16, 2019, 12:00 – 1:30 EDT
Guest Speaker: Martha Sanchez, MD; Natasha Rybak, MD

This webinar provided information on HIV co-infections and covered the following topics:

• 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
• The importance of open communications between healthcare providers and patients about HIV disease

Webinar participants raised concerns about managing infants with HIV co-infections, management of HIV positive children with complications of TB, and the interaction of various drugs for co-infected children.  

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Webinar 6: Fostering Hope: The Role of Mental Health Care in HIV Treatment from Start to Finish
Date & Time: June 23, 2019, 12:00 – 1:30 EDT
Guest Speaker: Jamie Kenney, PhD; Aziz Soomro, MD

The 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

Webinar participants discuss the limited availability of facilities for pre- and post-testing counseling in Pakistan. The discussion covered factors such as raising awareness of mental health issues associated with HIV infection to doctors, nurses, and educators who encounter HIV infected patients, as well as instilling hope into patients to ultimately improve treatment compliance, decrease suffering, and improve patients’ quality of life.

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