Unsafe injection practices contribute to HIV outbreak among children in Pakistan
An HIV outbreak among children in Sindh, Pakistan, was associated with multiple recent injections or infusions, blood transfusion and a higher number of visits to health care facilities, according to results of a case-control study.
The findings, which were presented during the AIDS 2020 virtual meeting, suggest that the most common mode of transmission in the outbreak was unsafe injection practices.
“Immediate clinical implications include a need to create a pediatric HIV service where there are none, assemble a team to provide appropriate care where there was none and procure a sustainable supply of child-friendly [antivirals] in a country where children are only 4.3% of total [people living with HIV] and procurement is done at least 1 to 2 years in advance through [The Global Fund to Fight AIDS, Tuberculosis and Malaria] support,” Fatima Mir, MBBS, FCPS, MsCR, associate professor in the department of pediatrics and child health at The Aga Khan University Karachi in Pakistan, told Healio. “Less immediate clinical implications include a need for expansion of testing services across the country (as a history of ‘unsafe’ injections and blood transfusions is an important risk factor for HIV acquisition among children in Pakistan and poor infection control practices are ubiquitous across the country), a need to train program physicians to test and treat children at least to a basic extent, a need to improve health literacy among the community to improve health-seeking behaviors and minimize risky behaviors like demanding injections.”
Mir and colleagues performed a household-based, individual-matched case-control study. They evaluated 1,167 children who tested positive for HIV during an outbreak in Larkana District in Sindh that occurred in April 2019. The researchers matched children aged younger than 16 years that registered for pediatric HIV care in Larkana City with a control group of uninfected children by age, sex and neighborhood. The researchers collected serum for hepatitis B and C virus serology from all participants and tested the patients’ mothers for HIV.
A total of 806 children, 403 of whom were HIV-positive and 403 of whom were in the control group, were evaluated. HBV surface antigen and HCV antibody rates were 18.4% (95% CI, 14.7-22.5) and 6.5% (95% CI, 4.3-9.3), respectively, among patients with HIV and 5.2% (95% CI, 3.3-7.9) and 1% (95% CI, 0.3-2.5), respectively, in the control group. Only 7% of all mothers tested were HIV-positive.
A total of 56.6% of HIV-positive children and 7.9% of children in the control group reported receiving more than 10 injections during the 6 months before being tested for HIV, whereas 72.7% of HIV- positive children and 19.3% of children in the control group reported receiving an infusion during the same time period. Additionally, 13.9% of children in the HIV group and less than 1% of children in the control group received one or more blood transfusions.
Researchers found that HIV infection independently correlated with the mother’s occupation, a history of blood transfusions (adjusted OR = 115.6; 95% CI, 6.4-2,091), a history of more infections or infusions (aOR = 1.5; 95% CI, 1.2-1.9), one or more visits to a government hospital (aOR = 19.9; 95% CI, 2.6-155.2) and a greater number of visits to private clinics (aOR = 3.1; 95% CI, 1.9-5.2) 6 months before being tested for HIV.
Mir noted that the study’s limitations included selection and recall bias, as well as an inability to establish a temporal relationship between risk factors and the timing of HIV infections.
“Clinicians should think about HIV in children with a history of transfusion, especially if the donor was unknown, and frequent injections, and acquire skills to test for, and treat, HIV.”