By Dr Younis Chachar
Pakistan’s HIV epidemic is undergoing a fundamental epidemiological transition. While historically concentrated among specific key populations, recent outbreaks have demonstrated that HIV is increasingly becoming a broader public health and health systems challenge affecting children, women, adolescents and the wider community. Unsafe injection practices, inadequate infection prevention and control (IPC), unsafe blood transfusions, delayed diagnosis, weak healthcare regulation and persistent stigma are contributing to preventable HIV transmission, highlighting the need to shift from disease-specific interventions towards integrated, community-based prevention and stronger health systems. Pakistan’s HIV epidemic is undergoing a profound epidemiological transition.
Traditionally regarded as a concentrated epidemic affecting defined key populations, HIV is increasingly emerging as a broader public health and health systems challenge that threatens the wider population, including children, adolescents, women and young adults. While key populations continue to require targeted prevention and treatment services, recent evidence demonstrates that HIV transmission in Pakistan can no longer be understood solely through the lens of behavioral risk. The epidemic is increasingly driven by systemic weaknesses within the healthcare system, including unsafe injection practices, inadequate infection prevention and control (IPC), unsafe blood transfusions, delayed diagnosis, fragmented referral pathways, weak regulation of healthcare facilities and persistent stigma that limits timely access to testing and treatment.
Repeated HIV outbreaks over the past decade have fundamentally altered our understanding of the epidemic. The 2019 outbreak in Ratodero first drew international attention to large-scale healthcare-associated HIV transmission among children. Since then, similar outbreaks have been reported in Mirpurkhas, Taunsa, Karachi and other districts, with investigations repeatedly linking new infections to the reuse of contaminated syringes, unsafe blood transfusions, poor infection prevention practices and inadequately regulated healthcare services. Most recently, the investigation into the HIV outbreak at Karachi’s Kulsum Bai Valika Hospital reinforced growing concerns that unsafe healthcare practices continue to expose entire communities — not only recognized key populations — to preventable HIV infection.
Collectively, these outbreaks signal a paradigm shift in Pakistan’s HIV epidemic and call for a broader, systems-oriented public health response. Sindh remains the most heavily affected province in Pakistan in terms of HIV burden and newly reported infections. Several districts, including Larkana, Mirpurkhas, Hyderabad and Karachi, continue to experience rapid increases in prevalence, particularly among children and rural populations, indicating gaps in screening, infection prevention practices and linkage to treatment services. Recently, an HIV outbreak erupted at Kulsum Bai Valika Hospital in Karachi, where more than 203 children were reportedly infected, triggering widespread concern over infection prevention and patient safety practices at the healthcare facility.
Authorities alleged that negligence by hospital staff contributed to the spread of the virus, prompting a formal investigation to determine responsibility and recommend disciplinary measures. According to the World Health Organization (WHO), Sindh has experienced multiple concentrated HIV outbreaks in recent years, driven largely by unsafe medical practices, weak infection control and inadequate regulation of informal healthcare providers. In 2024, Mirpurkhas was identified as a new HIV hotspot, with 150 children testing positive, representing approximately 26% of all paediatric HIV cases reported in the province that year. Sindh reported an average of 260 newly diagnosed HIV cases per month in 2024, of which 10 to 15% occurred in children under the age of 12.
The province has an estimated 90,000 people living with HIV, yet only 19,766 are currently registered across the 16 functional treatment and support centers, highlighting significant gaps in screening, diagnosis and treatment enrolment. More than 300 HIV-infected children died between 2019 and 2023, primarily in Larkana and adjoining areas, due to late diagnosis and limited linkage to antiretroviral therapy. Epidemiological analyses also reveal that many HIV-positive children have HIV-negative parents, indicating transmission through reused syringes, intravenous lines, unsafe injections and unregulated clinics, rather than through vertical (mother-to-child) transmission.
These data demonstrate an urgent need for expanded community-based screening, counselling services, infection prevention training and stronger referral systems, aligned with the WHO Test–Treat–Retain strategy and combination prevention framework. Key features requiring urgent attention include a clustering of newly diagnosed cases among children, which is highly unusual for HIV in Pakistan and suggests non-vertical (non-mother-to-child) transmission. There is also clear evidence that unsafe medical and healthcare practices, including the reuse of injections, unregulated clinics and inadequate infection prevention and control, are major drivers of transmission across multiple districts.
Weaknesses in screening, surveillance and linkage to prevention and treatment services, including antiretroviral therapy (ART), continue to undermine the provincial response. Furthermore, the geographic spread of the problem is significant. Outbreaks have been documented in rural districts such as Larkana as well as urban centers including Karachi, indicating that the epidemic is no longer confined to traditionally recognized key populations. Therefore, in Sindh, these factors — the high burden among children, unsafe healthcare practices and persistent gaps in service linkage — make a compelling case for targeted interventions in screening, infection prevention and control, healthcare regulation and stronger linkage to treatment services.
(The writer is an ex-provincial program manager Sindh AIDS Control Program and senior health consultant. He can be reached at editorial@metro-morning.com)
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