The etiology of the underlying immune deficiencies seen in AIDS cases is unknown. One hypothesis consistent with current observations is that a transmissible agent may be involved. If so, transmission of the agent would appear most commonly to require intimate, direct contact involving mucosal surfaces, such as sexual contact among homosexual males, or through parenteral spread, such as occurs among intravenous drug abusers and possibly hemophilia patients using Factor VIII products. Airborne spread and interpersonal spread through casual contact do not seem likely. These patterns resemble the distribution of disease and modes of spread of hepatitis B virus, and hepatitis B virus infections occur very frequently among AIDS cases.
There is presently no evidence of AIDS transmission to hospital personnel from contact with affected patients or clinical specimens. Because of concern about a possible transmissible agent, however, interim suggestions are appropriate to guide patient-care and laboratory personnel, including those whose work involves experimental animals. At present, it appears prudent for hospital personnel to use the same precautions when caring for patients with AIDS as those used for patients with hepatitis B virus infection, in which blood and body fluids likely to have been contaminated with blood are considered infective. Specifically, patient-care and laboratory personnel should take precautions to avoid direct contact of skin and mucous membranes with blood, blood products, excretions, secretions, and tissues of persons judged likely to have AIDS. The following precautions do not specifically address outpatient care, dental care, surgery, necropsy, or hemodialysis of AIDS patients. In general, procedures appropriate for patients known to be infected with hepatitis B virus are advised, and blood and organs of AIDS patients should not be donated.
The precautions that follow are advised for persons and specimens from persons with: opportunistic infections that are not associated with underlying immunosuppressive disease or therapy; Kaposi’s sarcoma (patients under 60 years of age); chronic generalized lymphadenopathy, unexplained weight loss and/or prolonged unexplained fever in persons who belong to groups with apparently increased risks of AIDS (homosexual males, intravenous drug abusers, Haitian entrants, hemophiliacs); and possible AIDS (hospitalized for evaluation). Hospitals and laboratories should adapt the following suggested precautions to their individual circumstances; these recommendations are not meant to restrict hospitals from implementing additional precautions.
- The following precautions are advised in providing care to AIDS patients:
- Extraordinary care must be taken to avoid accidental wounds from sharp instruments contaminated with potentially infectious material and to avoid contact of open skin lesions with material from AIDS patients.
- Gloves should be worn when handling blood specimens, blood-soiled items, body fluids, excretions, and secretions, as well as surfaces, materials, and objects exposed to them.
- Gowns should be worn when clothing may be soiled with body fluids, blood, secretions, or excretions.
- Hands should be washed after removing gowns and gloves and before leaving the rooms of known or suspected AIDS patients. Hands should also be washed thoroughly and immediately if they become contaminated with blood.
- Blood and other specimens should be labeled prominently with a special warning, such as “Blood Precautions” or “AIDS Precautions.” If the outside of the specimen container is visibly contaminated with blood, it should be cleaned with a disinfectant (such as a 1:10 dilution of 5.25% sodium hypochlorite (household bleach) with water). All blood specimens should be placed in a second container, such as an impervious bag, for transport. The container or bag should be examined carefully for leaks or cracks.
- Blood spills should be cleaned up promptly with a disinfectant solution, such as sodium hypochlorite (see above).
- Articles soiled with blood should be placed in an impervious bag prominently labeled “AIDS Precautions” or “Blood Precautions” before being sent for reprocessing or disposal. Alternatively, such contaminated items may be placed in plastic bags of a particular color designated solely for disposal of infectious wastes by the hospital. Disposable items should be incinerated or disposed of in accord with the hospital’s policies for disposal of infectious wastes. Reusable items should be reprocessed in accord with hospital policies for hepatitis B virus-contaminated items. Lensed instruments should be sterilized after use on AIDS patients.
- Needles should not be bent after use, but should be promptly placed in a puncture-resistant container used solely for such disposal. Needles should not be reinserted into their original sheaths before being discarded into the container, since this is a common cause of needle injury.
- Disposable syringes and needles are preferred. Only needle-locking syringes or one-piece needle-syringe units should be used to aspirate fluids from patients, so that collected fluid can be safely discharged through the needle, if desired. If reusable syringes are employed, they should be decontaminated before reprocessing.
- A private room is indicated for patients who are too ill to use good hygiene, such as those with profuse diarrhea, fecal incontinence, or altered behavior secondary to central nervous system infections. Precautions appropriate for particular infections that
concurrently occur in AIDS patients should be added to the above, if needed.
B. The following precautions are advised for persons performing laboratory tests or studies on clinical specimens or other potentially infectious materials (such as inoculated tissue cultures, embryonated eggs, animal tissues, etc.) from known or suspected AIDS cases:
- Mechanical pipetting devices should be used for the manipulation of all liquids in the laboratory. Mouth pipetting should not be allowed.
- Needles and syringes should be handled as stipulated in Section\A (above).
- Laboratory coats, gowns, or uniforms should be worn while working with potentially infectious materials and should be discarded appropriately before leaving the laboratory.
- Gloves should be worn to avoid skin contact with blood, specimens containing blood, blood-soiled items, body fluids, excretions, and secretions, as well as surfaces, materials, and objects exposed to them.
- All procedures and manipulations of potentially infectious material should be performed carefully to minimize the creation of droplets and aerosols.
- Biological safety cabinets (Class I or II) and other primary containment devices (e.g., centrifuge safety cups) are advised whenever procedures are conducted that have a high potential for creating aerosols or infectious droplets. These include centrifuging, blending, sonicating, vigorous mixing, and harvesting infected tissues from animals or embryonated eggs. Fluorescent activated cell sorters generate droplets that could potentially result in infectious aerosols. Translucent plastic shielding between the droplet-collecting area and the equipment operator should be used to reduce the presently uncertain magnitude of this risk. Primary containment devices are also used in handling materials that might contain concentrated infectious agents or organisms in greater quantities than expected in clinical specimens.
- Laboratory work surfaces should be decontaminated with a disinfectant, such as sodium hypochlorite solution (see A5 above), following any spill of potentially infectious material and at the completion of work activities.
- All potentially contaminated materials used in laboratory tests should be decontaminated, preferably by autoclaving, before disposal or reprocessing.
- All personnel should wash their hands following completion of laboratory activities, removal of protective clothing, and before leaving the laboratory. C. The following additional precautions are advised for studies involving experimental animals inoculated with tissues or other potentially infectious materials from individuals with known or suspected AIDS.
- Laboratory coats, gowns, or uniforms should be worn by personnel entering rooms housing inoculated animals. Certain nonhuman primates, such as chimpanzees, are prone to throw excreta and to spit at attendants; personnel attending inoculated animals should wear molded surgical masks and goggles or other equipment sufficient to prevent potentially infective droplets from reaching the mucosal surfaces of their mouths, nares, and eyes. In addition, when handled, other animals may disturb excreta in their bedding. Therefore, the above precautions should be taken when handling them.
- Personnel should wear gloves for all activities involving direct contact with experimental animals and their bedding and cages. Such manipulations should be performed carefully to minimize the creation of aerosols and droplets.
- Necropsy of experimental animals should be conducted by personnel wearing gowns and gloves. If procedures generating aerosols are performed, masks and goggles should be worn.
- Extraordinary care must be taken to avoid accidental sticks or cuts with sharp instruments contaminated with body fluids or tissues of experimental animals inoculated with material from AIDS patients.
- Animal cages should be decontaminated, preferably by autoclaving, before they are cleaned and washed.
- Only needle-locking syringes or one-piece needle-syringe units should be used to inject potentially infectious fluids into experimental animals. The above precautions are intended to apply to both clinical and
research laboratories. Biological safety cabinets and other safety equipment may not be generally available in clinical laboratories. Assistance should be sought from a microbiology laboratory, as needed, to assure containment facilities are adequate to permit laboratory tests to be conducted safely. Reported by Hospital Infections Program, Div of Viral Diseases, Div of Host Factors, Div of Hepatitis and Viral Enteritis, AIDS Activity, Center for Infectious Diseases, Office of Biosafety, CDC; Div of Safety, National Institutes of Health.
KARACHI: Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/Aids) is claiming more lives in Pakistan than ever, says a first-of-its-kind analysis of trend data from 188 countries released on Monday.
There has been an 11 per cent increase in mortality rates from HIV/Aids in Pakistan, according to the study that examines data from 2000 to 2013. However, it reports a decline in the death rates from tuberculosis (TB) and malaria in Pakistan since 2000, when the Millennium Development Goals (MDGs) were established to stop the spread of these diseases by 2015.
Published in The Lancet, the study Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 was conducted by an international consortium of researchers led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.
“Working closely with our WHO office, Pakistan has prioritised tackling tuberculosis and malaria, and I think we are seeing what happens when you invest in improving the prompt diagnosis and treatment of these deadly diseases. Now, we need to make sure that HIV/Aids does not take more lives in Pakistan than it already has,” said Prof Zulfiqar Bhutta, founding director of the Centre of Excellence in Women and Child Health at the Aga Khan University and co-director at the Centre for Global Child Health at The Hospital for Sick Children, and one of the study’s co-authors.
The AKU was also represented by Dr Mohammad Imran Nisar, senior instructor of the department of paediatrics and child health.
Globally, HIV/Aids and tuberculosis kill fewer people than they have in the past and the decline in new cases and deaths from these diseases have accelerated since 2000.
Worldwide, deaths from HIV/Aids declined at a rate of 1.5 per cent between 2000 and 2013, while tuberculosis deaths declined by 3.7pc.
Pakistan, however, is experiencing the opposite with HIV/Aids, according to the study.
“Increasingly, more people have died from HIV/Aids since 1990. From 2000 to 2013, the country averaged a 15 per cent annual increase in rates of new HIV/Aids infections, ultimately rising from less than 1 case per 100,000 to 6.7 per 100,000.
“Far more Pakistanis die from TB each year (nearly 37,500 were killed by TB in 2013), but the country’s ongoing progress in reducing TB mortality rates starkly contrasts with its burgeoning HIV/Aids burden,” the study says.
After adjusting for differences in population size and ages across time, researchers found that there were 277 cases of TB per 100,000 people in Pakistan for 2013. In terms of new cases, Pakistan recorded 151 TB cases per 100,000 that year.
Mortality rates from HIV/Aids in Pakistan (1.5 deaths per 100,000), according to the study, were higher than what was found in Afghanistan and Iran for 2013 (each were fewer than one death per 100,000) but remained lower than in India (6.6 deaths per 100,000).
TB death rates in Pakistan (32 deaths per 100,000) were lower than those in India (58 deaths per 100,000), but were much higher than the TB mortality rates in Iran for 2013 (2.8 deaths per 100,000).
“With progress in reducing HIV/Aids at the global level, success in particular countries and regions varied as their HIV epidemics peaked and declined at different times.
“The rise in the rates for HIV/Aids in Pakistan, at a time when most countries are recording progress against the disease, exemplifies this finding and underscores the need for action.
But since HIV/Aids still claims fewer lives in Pakistan than other infectious diseases, namely tuberculosis, the country may have the opportunity to halt its epidemic earlier than other places could in the past,” it says.
Earlier and more effective treatment, the study points out, has also helped shorten the duration of tuberculosis infections worldwide. However, the authors note that aging of the population will lead to higher numbers of cases and deaths. In both Pakistan and at the global level, the bulk of tuberculosis deaths tend to occur in older age groups.
The study also assessed trends in annual malaria cases and deaths throughout the world. From 2000 to 2013, Pakistan reduced its malaria mortality rates by an average of 4.6pc each year, recording 3,160 malaria deaths in 2013. Pakistan also had reductions, although less pronounced, in malaria cases, dropping 2.9pc annually between 2000 and 2013.
In comparison to many countries in sub-Saharan Africa and Southeast Asia, where malaria claims tens of thousands lives each year (over 260,000 people died from malaria alone in Nigeria last year), malaria claims relatively fewer lives in Pakistan.
The global malaria epidemic peaked in the early 2000s, at 232 million cases in 2003 and 1.2 million deaths in 2004. There were 164.9 million malaria cases and 854,566 deaths due to malaria in 2013 worldwide.
Published in Dawn,
For a long time perceptions of Pakistan as a conservative Muslim country encouraged a belief that HIV-Aids incidence would be non-existent or very low. With the number of HIV cases rising the government finally included it in its 2009 national health policy, but as the BBC’s Nosheen Abbas reports, its full extent is still not widely acknowledged.
A report on HIV by the UN last year said that 2003 was a key date in the battle against the disease in Pakistan.
At that time there was an outbreak of the epidemic when it was discovered that 10% of people among a random sample tested in the city of Larkana city in the province of Sindh were infected.
The findings moved Pakistan up from “low prevalence – high risk” category to a “concentrated epidemic”.
The epidemic is concentrated in pockets of high risk groups – including injecting drug users (IDUs), and male, female and hijra (transvestite) sex workers.
‘Attitude of apartheid’
A large number of HIV and Aids cases are also detected among migrants returning from Gulf states.
The UN report says that while the prevalence of HIV is low – only 0.1% among the general population – the growing commercial sex industry’s overlap with high risk groups is likely to cause the epidemic to spread to the general population.
But experts say the epidemic is not being properly tackled.
Asim Ashraf found out that he was infected with HIV when he was 18.
The mandatory medical test for Haj pilgrimage applicants showed his medical status, but he recalls the doctor being hesitant to break the news.
“I didn’t know anything about it, all the ads used to state that Aids was not curable and it’s a death sentence – I thought I would die in a couple of days or hours,” he says.
After a couple of tests Asim was lucky finally to find a doctor who explained HIV to him and helped him focus on living life as normally as possible.
But when Asim returned to his day job he was ostracised by his fellow workers, who would not sit and eat with him in what he describes as an “attitude of apartheid”.
He says his isolation worsened his health.
After studying the illness he is now the HIV-Aids co-ordinator at Rehnuma Family Planning Association. He is married and has a baby daughter – neither she nor his wife is infected with the virus.
Awareness campaigns regarding the epidemic are almost non-existent in Pakistan.
Jamshed is HIV-positive and a UNAIDS employee. He argues that “people avoid going to HIV and Aids clinics because there is such a strong stigma around the epidemic”.
“They don’t get themselves registered, least of all get themselves tested for HIV because many argue that we are an Islamic country and we do not have this problem,” he says.
The belief that HIV and Aids is an epidemic caused by “immoral activities” remains a popular misconception among the general public.
The efforts of those fighting against the illness have been hampered by the deteriorating security situation in many parts of the country and by this cultural mindset.
‘Walking on eggshells’
Non-governmental organisations (NGOs) working to fight HIV and Aids in the region have received threats and have either changed the location of their offices or only function by telephone.
Palvasha, a 30-year-old Pashtun woman who is HIV-positive, counsels others with the illness in the country’s tribal areas where militants have a strong presence.
“Patients are made to sit outside on the lawn far away from the office itself – the reason is the fear of suicide attacks,” Palvasha says.
She describes the difficulties of providing counselling to HIV-positive people in the region as “akin to walking on eggshells”.
“You need to imply a lot and not talk about things in a direct manner – using one wrong word could send you out of people’s houses.
“We are afraid to hold awareness campaigns because we get accused of spreading wrong and sinful things – so we have to be very tactful.”
The UN says that the country’s anti-Aids programme is short of cash and bedevilled by bureaucracy – especially when it comes to the release of funds that have been committed.
But female Pakistani parliamentarian Donya Aziz argues that the government has been forward-thinking about the crisis, handling it in a pragmatic way.
“Despite being an Islamic republic, many programmes have been designed for high risk groups,” she says.
“The penal code states sodomy as a crime for example, yet we have programmes geared towards male partners… But we do need to spend the money in a cost-effective way.”