This spring, a number of parents in Ratodero, a poor neighborhood in the city of Larkana in southern Pakistan, were worried about their children.
Their kids had been running a fever for a while. Their parents had been taking them to a clinic run by Dr. Muzaffar Ghangharo, a pediatrician. But the youngsters weren't responding to treatments to bring down the fever.
In late April, some of the parents wanted another opinion. So they took their children to a different medical center in Larkana, where they were seen by Dr. Imran Arbani.
Because a long-running fever is one of the symptoms of HIV, Dr. Arbani suggested testing the children for the virus as a precaution.
The results were devastating. On April 24, the first test results came in: One of the children was HIV positive. There were 14 more positive test results, according to an op-ed written by Muhammad Nauman Siddique, the province's deputy commissioner, and published on May 20.
The children ranged in age from 2 months to 8 years.
That was the start of the current HIV outbreak in the Sindh province of Pakistan.
It's a disease that is all too familiar in this part of the country. The province accounts for nearly half of the 150,000 HIV positive cases in Pakistan, according to UNAIDS. In this particular outbreak, blame was initially focused on Dr. Ghangharo but the tragedy is now being linked to major failures in the health-care system, including reuse of syringes and lack of standards for blood transfusions.
After news of the infected children broke on TV, "there was panic, hue and cry," Masood Bangash, a district police officer, told NPR. Parents gathered outside Dr. Ghangharo's clinic and other sites in Larkana to express their anger.
The deputy commissioner of Larkana's municipal government called for free screenings for anyone who was concerned. The parents of the HIV positive children demanded that Dr. Ghangharo be screened as well.
As of May 20, more than 10,000 children and adults have been screened as part of the ongoing government effort. In total, 607 were HIV positive: 113 adults and 494 children. According to the authorities, in most cases the parents of these children are not HIV positive.
As for Dr. Ghangharo, he was found to be HIV positive.
"And here is when it was suspected that he was the source of spreading HIV in their kids through bad practices," says Bangash.
Dr. Ghangharo says he was not previously aware of this status. and the police said that he believes he might have been infected from a blood transfusion he received after an automobile accident several years ago.
Because of the outcry, the doctor was arrested on April 30 based on what's known as a "first information report" in the Pakistani judicial system — in this case, complaints from the parents about a possible offense. He is being held in jail until an investigation of the matter is completed.
In a video filmed in jail that day and released on social media, the doctor stated: "I have been accused of playing the main role in spreading HIV. I am a qualified pediatrician. I had no idea I was infected. I would have taken treatment had I known I had HIV. I never felt any signs and symptoms. I am fully active. Also, why would I do this to innocent kids? What enmity do I have against these innocent children that I will infect them with HIV?"
The investigation is still going on as the team tries to determine if the outbreak was due to unsafe practices in the doctor's clinic and other clinics in the region.
Dr. Minhaj Kidwai, the CEO of the Sindh Health Care Commission, an independent, government-funded group, believes that the outbreak is a result of "contaminated syringes, syringes that are reused for injections in children, unscreened blood transfusions and reuse of dextrose and saline drips."
Fehmida Khan, community support adviser at the UNAIDS Country Office for Pakistan and Afghanistan, reiterated that theory in an email to NPR: "For now, it seems that the major mode of transmission ... is attributed to the rampant practice of unsafe injections and unsafe blood transfusion.
Because of the hundreds of diagnoses since April, the belief is that it's impossible to blame one individual. "It's not only this particular doctor but others and quacks as well," says Kidwai.
According to the Pakistan Medical and Dental Council, an estimated 200,000 unqualified medical personnel are practicing in the province of Sindh.
What's more, even if medical staff dispose of needles, there are still risks, the investigators found. "During our investigation we also unearthed people who were repackaging used syringes and selling them to doctors," says Kidwai.
In all of Sindh province, Kidwai says, investigators have identified some 500 clinics, labs and blood banks with unsafe practices or evidence of quackery in the last three weeks. In Larkana alone, 147 facilities have been "sealed" — shut down pending further investigation. And approximately 600 facilities in Sindh province have received government warnings.
There's another potential problem, Kidwai says. Some doctors in the area "sublet" their degrees to non-medical personnel, who'll pay a fee so they can state the clinic is under the doctor's supervision even though the doctor is not on the premises.
Saeed Ahmed Awan, secretary of the Sindh Health Department, is calling attention to another source of HIV transmission in Larkana: barbershops.
Transmission could occur, says Awan, because some barbers reuse razor blades. A 2014 study published by NIH notes: "Poor barbering practices ... potentiates a great risk for aggravating the HIV endemic in Pakistan."
In certain villages in Pakistan, parents still take infants and young boys to barbers for circumcision.
Awan, the health secretary, believes that HIV was introduced to the region through residents who traveled to Gulf states as migrant workers, engaged in unsafe sex with local sex workers, then brought the virus back to Larkana.
"HIV has been prevalent in Larkana for some time," says Dr. Bushra Jamil, a professor of infectious diseases at the Aga Khan University. "Therefore I believe that transmission has been going on and has been discovered now."
And this is not the first HIV outbreak in Larkana, says Jamil. In September 2016, she says, an HIV outbreak was identified at Civil Hospital Larkana, a government facility, in dialysis patients. "Around 50 cases of HIV had emerged in the kidney patients who had regularly been getting dialysis at this unit," she says.
Investigators found that the patients contracted the virus because of unsafe practices during the dialysis process.
The challenge now for local authorities is to care for the infected children and adults as well as to address the possible causes of the outbreak. Aga Khan University as a private entity "can guide the government when requested but the strategy to tackle this outbreak comes from the government," she says.
"Beside the screenings we are also planning to arrange psycho-social support for affectees and their families," Azra Puchuho, the health minister of Sindh province, told NPR.
The local government has allocated 30 million rupees — more than $400,000 — to obtain HIV test kits, according to Fehmida Khan of UNAIDS. And there are plans to establish an office in Larkana to implement existing provincial acts calling for safe practices regarding syringes and transfusions.
The U.N. is playing a role as well.
Khan emailed NPR: "UNAIDS, UNICEF, WHO and other U.N. agencies are closely collaborating with Health Department, Government of Sindh, to stop unlicensed informal medical practices and to ensure that the UN's collective action will complement the government's efforts to effectively address the critical gaps in preventing new HIV infections."
At Aga Khan University, there's a strong commitment to educating all medical personnel. "In the long run we are planning to train physicians [and other health workers], train them again and again to refresh about best practices," says Dr. Jamil.
In light of this outbreak, she urges that citizens be educated as well: "to say no to unnecessary injections."
Meanwhile, the outbreak has had a chilling effect on daily life in Larkana. Some people in the district are so panicked that they're avoiding social gatherings because they're afraid to mingle — even though HIV cannot be transmitted through casual contact. And on Twitter, one man reports that he bought an electric razor so he can give himself a shave instead of going to the barbershop — and give his kids haircuts as well.
Benazir Samad is a journalist from Pakistan currently in the U.S. as part of the Hubert H. Humphrey Fellowship Program, a Fulbright program that is sponsored by the U.S. State Department. She tweets @benazirmirsamad
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