HIV-infected workers deported from the Gulf States: impact on Southern Pakistan

Systematic Review of Reported HIV Outbreaks, Pakistan, 2000-2019

In the absence of robust testing programs, timely and detailed outbreak reporting is essential for HIV control.

Unsafe injection practices and injection drug use have been linked to multiple HIV outbreaks in Pakistan since 2003; however, few studies have systematically analyzed the causes of these outbreaks. We conducted a systematic review of published English-language literature indexed in bibliographic databases and search engines and a focused gray literature review to collate and analyze all reported HIV outbreaks in Pakistan during 2000–2019. Of 774 unique publications reviewed, we identified 25 eligible publications describing 7 outbreaks. More than half occurred during 2016–2019. The primary sources of transmission were iatrogenic transmission, affecting children, persons with chronic medical conditions, and the general population (4 outbreaks); injection drug use (2 outbreaks); and a combination of both (1 outbreak). In the absence of robust HIV testing and surveillance in Pakistan, timely and detailed outbreak reporting is important to understand the epidemiology of HIV in the country.

Identification of risk factors for human immunodeficiency virus-1 infection in Khyber Pakhtunkhwa population: A case control study

OBJECTIVES

The present study aims to identify the risk factors for Human Immunodeficiency Virus-1(HIV-1) infection in Khyber Pakhtunkhwa (KP) population by comparing HIV-antibody positive cases with HIV-antibody-negative controls.

METHODS

The study was designed at the Family Care Centre (FCC), Hayatabad Medical Centre (HMC) Peshawar from February 2015 to December 2016. A total of 280 individuals were selected randomly for the study as cases and control. Data was collected on a structured questionnaire with informed oral consent. The collected data was analysed statistically using SPSS version 20.

RESULTS

Out of 280 individuals, 56% were males, 44% were females, and 53.21% belonged to the urban areas. The literacy rate was 48.6%, and 75.4% were married. The statistical analysis of risk factors revealed the following factors as of significance value (p < 0.05). Family history of HIV (OR = 9.46), spouse status of HIV (OR=22.22), injection drug users (IDUs), migrants (OR=2.234), use of therapeutic injections (OR= 2.791), employment (OR=2.545), male gender (OR=2.35), tattooing (OR=7.667) and history of blood transfusion (OR= 2.69).

CONCLUSION

The present study revealed spouse status of HIV, tattooing, migrants, IDUs, use of therapeutic injections, history of blood transfusion, male gender and employment as significant risk factors for HIV infection in the population of KP.

Late diagnosis of human immunodeficiency virus infections in high-risk groups in Karachi, Pakistan

Human immunodeficiency virus (HIV) infection prevalence in Pakistan has been increasing in high-risk groups, including people who inject drugs (PWID) and transgender hijra sex workers (TG-HSWs) nationwide. Effective control of HIV requires early diagnosis of the infection. We investigated recency of HIV infections in newly-diagnosed cases in PWID and TG-HSWs. This was an observational study with convenience sampling. Overall, 210 HIV-positive subjects comprising an equal number of PWID and TG-HSWs were included. Antibody avidity was tested using the Maxim HIV-1 Limiting Antigen Avidity (LAg) EIA (Maxim Biomedical, Inc. Rockville, Maryland, USA). The mean age of study subjects was 29.5 years: PWID, 28.5 years and TG-HSWs, 30.4 years. Study subjects were married, 27%, or unmarried. Eighteen percent of individuals had recently-acquired HIV infections: 19% of PWID and 17% of TG-HSWs. Eighty-two percent of individuals had long-term HIV infections: 81% of PWID and 83% of TG-HSWs. This is the first study identification of recent HIV-1 infections in Pakistan. We show that most newly-diagnosed HIV patients in the high-risk groups studied had long-term infections. There is an urgent need for intervention in these groups to facilitate early diagnosis and treatment of HIV infection to reduce transmission in Pakistan.

Heterogeneity in geographical trends of HIV epidemics among key populations in Pakistan: a mathematical modeling study of survey data

BACKGROUND

Assessing patterns and trends in new infections is key to better understanding of HIV epidemics, and is best done through monitoring changes in incidence over time. In this study, we examined disparities in geographical trends of HIV epidemics among people who inject drugs (PWIDs), female sex workers (FSWs) and hijra/transgender/male sex workers (H/MSWs), in Pakistan.

METHODS

The UNAIDS Estimation and Projection Package (EPP) mathematical model was used to explore geographical trends in HIV epidemics. Four rounds of mapping and surveillance data collected among key populations (KPs) across 20 cities in Pakistan between 2005-2011 was used for modeling. Empirical estimates of HIV prevalence of each KP in each city were used to fit the model to estimate prevalence and incidence over time.

RESULTS

HIV incidence among PWIDs in Pakistan reached its peak in 2011, estimated at 45.3 per 1000 person-years. Incidence was projected to continue to rise from 18.9 in 2015 to 24.3 in 2020 among H/MSWs and from 3.2 in 2015 to 6.3 in 2020 among FSWs. The number of people living with HIV in Pakistan was estimated to steadily increase through at least 2020. HIV incidence peak among PWIDs ranged from 16.2 in 1997 in Quetta to 71.0 in 2010 in Faisalabad (per 1000 person-years). Incidence among H/MSWs may continue to rise through 2020 in all the cities, except in Larkana where it peaked in the early 2000s. In 2015, model estimated incidence among FSWs was 8.1 in Karachi, 6.6 in Larkana, 2.0 in Sukkur and 1.2 in Lahore (per 1000 person-years).

CONCLUSIONS

There exists significant geographical heterogeneity in patterns and trends of HIV sub-epidemics in Pakistan. Focused interventions and service delivery approaches, different by KP and city, are recommended.

Molecular diagnosis and phylogenetic analysis of human papillomavirus type-16 from suspected patients in Pakistan

Background

Human Papillomavirus (HPV) is well known pathogen that can cause benign and malignant tumors in humans, yet there is very little information regarding HPV types prevalent in Pakistan.

Methods

A total of 92 cervical secretions were collected from suspected married female patients and used for DNA isolation using a novel isolation method. The samples were tested through Polymerase Chain Reaction (PCR) using already reported primers MY09/MY11, GP5/GP6, GP5+/GP6+, CP65/CP70, CP66/CP69 and SPF1/SPF2 and with those developed in this study including HRT1 and HRT2 primer sets for typing HPV types and HACTB primer set for human beta actin gene as internal positive control. Sequencing and phylogenetic analyses were performed for two isolates to determine circulating HPV types.

Results

PCR with HRT1 and HRT2 indicated 2 (2.17 %) patients were positive for HPV type- 16 while 1 (1.08 %) with HPV type 18. Sequencing and phylogenetic analysis of isolates confirmed HPV type-16 in genus alpha 9 which have 99 % homology with already reported HPV from Japan and Costa Rica.

Conclusion

This is the first report of HPV type-16 genus alpha 9 in Pakistan and the reported assay and sequence data will serve as valuable tools in further epidemiological studies for HPV surveillance to improve public health, especially of females in Pakistan.

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless

Background

The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted.

Methods

We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion.

Results

Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3–14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (ARR = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04).

Conclusions

Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009–2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

HIV-related travel restrictions: trends and country characteristics

Introduction

Increasingly, HIV-seropositive individuals cross international borders. HIV-related restrictions on entry, stay, and residence imposed by countries have important consequences for this mobile population. Our aim was to describe the geographical distribution of countries with travel restrictions and to examine the trends and characteristics of countries with such restrictions.

Methods

In 2011, data presented to UNAIDS were used to establish a list of countries with and without HIV restrictions on entry, stay, and residence and to describe their geographical distribution. The following indicators were investigated to describe the country characteristics: population at mid-year, international migrants as a percentage of the population, Human Development Index, estimated HIV prevalence (age: 15–49), presence of a policy prohibiting HIV screening for general employment purposes, government and civil society responses to having non-discrimination laws/regulations which specify migrants/mobile populations, government and civil society responses to having laws/regulations/policies that present obstacles to effective HIV prevention, treatment, care, and support for migrants/mobile populations, Corruption Perception Index, and gross national income per capita.

Results

HIV-related restrictions exist in 45 out of 193 WHO countries (23%) in all regions of the world. We found that the Eastern Mediterranean and Western Pacific Regions have the highest proportions of countries with these restrictions. Our analyses showed that countries that have opted for restrictions have the following characteristics: smaller populations, higher proportions of migrants in the population, lower HIV prevalence rates, and lack of legislation protecting people living with HIV from screening for employment purposes, compared with countries without restrictions.

Conclusion

Countries with a high proportion of international migrants tend to have travel restrictions – a finding that is relevant to migrant populations and travel medicine providers alike. Despite international pressure to remove travel restrictions, many countries continue to implement these restrictions for HIV-positive individuals on entry and stay. Since 2010, the United States and China have engaged in high profile removals. This may be indicative of an increasing trend, facilitated by various factors, including international advocacy and the setting of a UNAIDS goal to halve the number of countries with restrictions by 2015.

Screening for HIV among tuberculosis patients: a cross-sectional study in Sindh, Pakistan

OBJECTIVE

To describe feasibility and results of systematic screening of tuberculosis (TB) patients for HIV.

DESIGN

Cross-sectional study.

SETTING

Six selected sentinel sites (public DOTS clinics) in the province of Sindh, Pakistan.

PARTICIPANTS

All TB patients aged 16-60 years registered for treatment from April 2008 to March 2012.

MEASUREMENT

Demographic information of registered TB patients, screening for HIV through rapid testing and confirmation by referral lab of Sindh AIDS Control Program, according to national guidelines.

RESULTS

Of a total of 18 461 registered TB patients, 12 882 fulfilled the inclusion criteria and were given education and counselling. Of those counselled 12 552 (97.4%) were screened for HIV using a rapid test. Men made up 48% of the sample and 76.5% of patients had pulmonary TB. Of the total patients tested, 42 (0.34%) were HIV-positive after confirmatory testing at the Sindh AIDS Control Program Laboratory. Prevalence of HIV among male patients was 0.67% whereas prevalence among female patients was 0.03% (p value <0.001). Prevalence of HIV among pulmonary TB patients was 0.29% and among extrapulmonary TB patients was 0.48% (p value=0.09).

CONCLUSION

In public DOTS clinics in Pakistan it is feasible to test TB patients for HIV. Prevalence of HIV is three times higher among TB patients as compared with the general population in Pakistan. Although the results are not representative of Pakistan or Sindh province they cover a large catchment area and closely match WHO estimate for the country. Routinely screening all TB patients for HIV infection, especially targeting men and ensuring antiretroviral therapy, can significantly improve TB/HIV collaborative activities in Pakistan and identify many cases of HIV, improve health outcomes and save lives.

Antiretroviral drug resistance mutations among treated and treatment-naive patients in Pakistan: diversity of the HIV type 1 pol gene in Pakistan

Pakistan is experiencing a growing HIV epidemic. Antiretroviral drugs (ARV) have been smuggled into the country and available without prescription since the early 1990s, but are now provided free of cost by the government. We assessed the prevalence of HIV-1, drug resistance, and subtype distributions. Blood specimens were collected from HIV-1-infected participants registered in Sindh Province on dry blood spot (DBS) cards in 2008. Pol, protease, and partial reverse transcriptase regions were sequenced after reverse transcriptase PCR (RT-PCR). HIV-1 subtype was assigned by phylogenetic analysis. Primary drug resistance was analyzed by the Calibrated Population Resistance (CPR) tool using the Stanford Surveillance Drug Resistance Mutation (SDRM) major mutation list. Out of 100 blood samples collected, 42 were suitable for testing. Out of 42, 11 were ARV-receiving and 31 ARV-naive patients. Among them, 24 were injection drug users (IDUs), four immigrants, two hijras (male transvestites), two men who have sex with men (MSM), four prisoners, one female sex workers, two spouses of HIV-infected persons, and four from the general population. ARV resistance among naive patients was 2/31 (6.5%) and 36.4% (4/11) among ARV-experienced patients making an overall resistance of 14.2%. HIV-1 subtype A1 was the predominant subtype found in 35/42 (83.3%) followed by CRF35_AD and C, 6.5% each. Subtype D and G were found in one (2.4%) each. A significant proportion of Pakistani HIV patients has ARV drug resistance. Physicians treating patients should consider the magnitude of drug resistance while selecting regimens, and address drug adherence aggressively.

The roles of labor migrants' wives in HIV/AIDS risk and prevention in Tajikistan

This study aimed to build formative knowledge regarding labor migrants' wives' knowledge, attitudes, and behaviors regarding HIV/AIDS risk and protection that would inform developing innovative HIV prevention strategies. This was a collaborative ethnography in Tajikistan that included minimally structured interviews and focused field observations with 30 Tajik wives in Dushanbe married to Tajik male migrant workers currently working in Moscow. The results documented the wives' concerns over their husbands' safety in Moscow and the difficulties of living without husbands. In a male-dominated society, gender norms limit the wives' abilities to protect themselves and their husbands from HIV/AIDS. They have some awareness of HIV/AIDS, but limited abilities to speak about sexual activity, HIV/AIDS, condoms, and HIV testing. Wives do not use condoms with their husbands and depend upon their husband's role as their protector. Wives often turn for support to their "circle of friends" or to a primary care nurse for support, but seldom do these relationships focus on preventing HIV/AIDS. To respond to HIV/AIDS risks amongst the wives of Tajik male migrant workers in Moscow, preventive interventions could build upon migrants' wives' role as the primary family caregiver and their existing sources of social support from women's circles and nurses. The overall intervention strategy could be to expand their role as family caregivers to include HIV/AIDS protection, through enhancing their HIV/AIDS knowledge and prevention skills and negotiation strategies with their husbands.

Evidence for a "Founder Effect" among HIV-infected injection drug users (IDUs) in Pakistan

Background

We have previously reported a HIV-1 subtype A infection in a community of injection drug users (IDUs) in Karachi, Pakistan. We now show that this infection among the IDUs may have originated from a single source.

Methods

Phylogenetic analysis was performed of partial gag sequences, generated using PCR, from 26 HIV-positive IDU samples.

Results

Our results showed formation of a tight monophyletic group with an intra-sequence identity of < 98% indicating a "founder effect". Our data indicate that the HIV-1 epidemic in this community of IDUs may have been transmitted by an HIV positive overseas contract worker who admitted to having contact with commercial sex workers during stay abroad.

Conclusion

Specific measures need to implemented to control transmission of HIV infection in Pakistan through infected migrant workers.

High-risk behaviours among juvenile prison inmates in Pakistan

OBJECTIVES

To assess the sexual- and drug-use-related risk behaviours of male juvenile detainees in Karachi, Pakistan.

DESIGN

Cross-sectional study.

METHODS

A cross-sectional study was conducted of prison inmates aged 15-21 years in Karachi Juvenile Prison in 2002. In total, 321 inmates were interviewed about sexual orientation and behaviours, and knowledge about human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). Urine specimens were collected and tested for Chlamydia trachomatis and Neisseria gonorrhoeae using ligase chain reaction.

RESULTS

A substantial proportion (n=111, 34.6%) of the participants were sexually active. Sixty-two (19%) and 67 (21%) had had sex with a male or female before incarceration, respectively. Twenty-seven (8.4%) participants had an STI, and 50% of the 109 sexually active participants had had multiple sexual partners. Use of addictive substances was associated with sexual activity. The mean knowledge score computed from the sum of 16 items was 4.7, with a median of 2.9. A large proportion (40%) of participants knew about condoms, but very few (3.4%) had ever used one. The mean+/-standard deviation risk score from nine items was 2.4+/-1.7. On the basis of behavioural and biological markers, 117 (36.4%) participants had high-risk behaviour. In multivariate logistic regression analysis, knowledge, risk perception and age were predictive of higher risk.

CONCLUSIONS

HIV risk behaviours are common among adolescent inmates. Although inmates do have knowledge about modes of transmission and condom use, the use of condoms is significantly low. Interventions are needed for behavioural change among this group.

Prevalence of HCV and HIV infections in 2005-Earthquake-affected areas of Pakistan

Background

On October 8, 2005, an earthquake of magnitude 7.6 hit the Northern parts of Pakistan. In the post-earthquake scenario, overcrowding, improper sewage disposal, contamination of food and drinking water, hasty surgical procedures, and unscreened blood transfusions to earthquake victims most likely promotes the spread of infections already prevalent in the area.

Objective

The objective of the study reported here was to determine the prevalence of Human Immunodeficiency and Hepatitis C viruses (respectively, HIV and HCV) in the earthquake-affected communities of Pakistan. The samples were analyzed 2 months and then again 11 months after the earthquake to estimate the burden of HIV and HCV in these areas, and to determine any rise in the prevalence of these viral infections as a result of the earthquake.

Methods

Blood samples were initially collected during December, 2005 to March 2006, from 245 inhabitants of the earthquake-affected areas. These samples were screened for HCV and HIV, using immunochromatography and Enzyme-Linked Immuno-Sorbent Assay (ELISA).

Results

Out of 245 samples tested, 8 (3.26%) were found positive for HCV, and 0 (0.0%) for HIV, indicating the existence of HCV infection in the earthquake-stricken areas. The same methods were used to analyze the samples collected in the second round of screening in the same area, in September, 2006 – 11 months after the earthquake. This time 290 blood samples were collected, out of which 16 (5.51%) samples were positive for HCV, and 0 for HIV.

Conclusion

A slightly higher prevalence of HCV was recorded 11 months after the earthquake; this increase, however, was not statistically significant. None of the study participants was found HIV-infected.

Expansion of HIV laboratory diagnostic services in Chennai, India 2001-2006: is the growth commensurate with the need?

OBJECTIVE

To describe the changes in HIV services provided and the patient population utilizing voluntary counseling and testing (VCT) services at private testing laboratories in Chennai, India in 2001 and 2006.

METHODS

In 2001, a cross-sectional descriptive survey was conducted to assess the services provided and client population of 1,031 private laboratories. A subset of labs (9%) that had been surveyed in 2001 were also studied in 2006.

RESULTS

In 2001, significantly more high volume labs (>10 HIV tests per month) offered HIV diagnostic tests than low volume labs (<10 HIV test per month) (p<0.001). More high volume labs (20.0%) provided pre-test counseling as part of HIV testing than low volume labs (11.1%) (p = 0.003). Between 2001 and 2006, the number of labs that provided HIV diagnostic tests significantly increased, including ELISA (87.8% vs. 40.0%), Western Blot (84.4% vs. 13.3%), and Tridot (98.9% vs. 72.2%) (p<0.001). Also the number of labs that reported greater than 10 women seeking HIV testing per month significantly increased from 14.5% to 79.0% (p = 0.006). More labs provided pre-test counseling in 2006 (34.4%) than in 2001 (21.1%) (p = 0.046).

CONCLUSIONS

Though HIV diagnostic testing services have increasingly become available, counseling services have not expanded commensurately. Further outreach and education is necessary to expand comprehensive HIV VCT services in both urban and rural India.

Risk factors for HIV infection in males who have sex with males (MSM) in Bangladesh

Background

Recent surveillance data from Bangladesh indicate rising HIV infection among intravenous drug users (IDU) in the country. We suggest a likely association between HIV risk factors in this group and other groups, such as males who have sex with males (MSM).

Methods

Data on MSM in Bangladesh was collected and analyzed from numerous primary and secondary sources, including government ministries, non-profit health organizations, and personal communications.

Results

The overall prevalence of HIV in Bangladesh is relatively low, but surveillance data indicate that infection has reached significant proportions in certain high-risk groups and may soon spread to other groups, specifically MSM.

Conclusion

The epidemiology of HIV infection in other countries suggests that increasing rates of HIV in higher-risk populations can precede an epidemic in the general population. We review the data concerning MSM, IDU and HIV in Bangladesh from a variety of sources and propose ways to prevent HIV transmission.

HIV/AIDS in Pakistan: the battle begins

Pakistan, the second most populous Muslim nation in the world, has started to finally experience and confront the HIV/AIDS epidemic. The country had been relatively safe from any indigenous HIV cases for around two decades, with most of the infections being attributable to deported HIV positive migrants from the Gulf States. However, the virus finally seems to have found a home-base, as evidenced by the recent HIV outbreaks among the injection drug user community. Extremely high-risk behavior has also been documented among Hijras (sex workers) and long-distance truck drivers. The weak government response coupled with the extremely distressing social demographics of this South-Asian republic also helps to compound the problem. The time is ripe now to prepare in advance, to take the appropriate measures to curtail further spread of the disease. If this opportunity is not utilized right now, little if at all could be done later.

High HCV seroprevalence and HIV drug use risk behaviors among injection drug users in Pakistan

Introduction

HIV and HCV risk behaviors among injection drug users (IDUs) in two urban areas in Pakistan were identified.

Methods

From May to June 2003, 351 IDUs recruited in harm-reduction drop-in centers operated by a national non-governmental organization in Lahore (Punjab province) and Quetta (Balochistan province) completed an interviewer-administered survey and were tested for HIV and HCV. Multivariable logistic regression identified correlates of seropositivity, stratifying by site. All study participants provided written, informed consent.

Results

All but two were male; median age was 35 and <50% had any formal education. None were HIV-positive; HCV seroprevalence was 88%. HIV awareness was relatively high, but HCV awareness was low (19%). Injection behaviors and percutaneous exposures such as drawing blood into a syringe while injecting ('jerking'), longer duration of injection, and receiving a street barber shave were significantly associated with HCV seropositivity.

Discussion

Despite no HIV cases, overall HCV prevalence was very high, signaling the potential for a future HIV epidemic among IDUs across Pakistan. Programs to increase needle exchange, drug treatment and HIV and HCV awareness should be implemented immediately.

Background demographics and risk behaviors of injecting drug users in Karachi, Pakistan

OBJECTIVE

To find the prevalence of HIV infection and risk behaviors among injecting drug users (IDUs) in Karachi, Pakistan.

DESIGN

A cross-sectional study of IDUs conducted in Karachi, Pakistan from February through June 1996.

RESULTS

Of the 242 IDUs, 11 (4%) refused HIV testing. One (0.4%; 95% confidence interval (CI) = 0.37-0.48%) was HIV positive. All subjects were male. Over the past 6 months 47% had engaged in receptive needle sharing, 38% had perceived a change in their social network, 22% had had sexual intercourse, of whom only 7% always used condoms, and none had washed their needles with bleach. Younger age (28 vs. 31 years; p = 0.01), younger age at first injection (25 vs. 28 years; p = 0.001), fewer years of schooling (3 vs. 5 years; p = 0.001), lower monthly income (70 dollars vs. 80 dollars; p = 0.03), inhaling fumes of heroin from a foil in the year before injecting (OR = 4.8; CI = 2.2-10.3), injecting first time with heroin (OR = 3.6; CI = 1.2-12.6), having a temporary job (OR = 2.5; CI = 1.2-5.2), and a perceived change in one's social network (OR = 4.4; CI = 2.4-7.9) were all associated with receptive needle sharing. IDUs who knew about HIV spread through contaminated needles were less likely to share (OR = 0.4; CI 0.2-0.8). In the final logistic regression model receptive needle sharing was associated with inhaling of fumes of heroin on a foil in the year prior to injecting (adjusted OR = 5.6; CI = 2.6-12.0), a perceived change in one's social network (adjusted OR = 4.0; CI = 2.2-7.4), and inversely associated with age at first time of injection (beta = -0.07; p = 0.002).

CONCLUSION

Background HIV prevalence was low among IDUs in Karachi despite high-risk behavior in 1996. In order to control HIV transmission among IDUs in Pakistan, continual HIV surveillance with well-coordinated and effective HIV risk reduction, and drug demand reduction programs need to be implemented among drug users.

HIV knowledge and risk behaviors among Pakistani and Afghani drug users in Quetta, Pakistan

Situated on the Pakistan-Afghan border, Quetta is home to growing numbers of Afghan refugees. We studied HIV knowledge and risk behaviors among Pakistani and Afghani drug users between July 2001 and November 2001. Of 959 drug users, all were male and the majority used heroin. Most were Pakistani (84.8%), 14.9% were Afghani, and 0.3% were Iranian. Relative to Pakistani drug users, a higher proportion of Afghanis reported no formal education, homelessness, and unemployment ( p <.001). Afghanis were more likely to have used an opiate as their first illicit drug (16% vs. 7%, p <.001), to have ever injected (18.8% vs. 12.3%, p =.04), to report needle sharing (72.2% vs. 48.2%, p =.08), or to report a drug user in their family ( p =.08). None of sexually active Afghanis had ever used a condom compared with 5.0% of the Pakistanis ( p =.01). Only 4.3% of Afghans had ever heard of HIV/AIDS compared with 18.3% of Pakistanis ( p <.001). Extremely low levels of HIV/AIDS awareness and high HIV risk behaviors were evident among drug users in Quetta, among whom Afghanis were especially vulnerable. Interventions to prevent transition to injection, needle exchange, and drug treatment are urgently required to prevent blood-borne infections.