HIV at a crossroads in Pakistan
Authors: Hussain A Raza, Mohummad H R Raja, Muhammad M Khakwani, Bushra Jamil
Journal: The Lancet HIV (2024)

Pakistan has low HIV prevalence (0·1%), with incidence on the rise and marginalised key populations bearing the brunt.1WHO Eastern Mediterranean RegionHIV in the WHO eastern mediterranean region.https://www.emro.who.int/asd/about/hiv-situation-region.htmlDate accessed: January 21, 2024Google Scholar Alarmingly, incidence is slowly rising in the general population. We believe that in Pakistan, the main reasons for continued spread of HIV are flawed preventive strategies, stigma, a major reliance on external funding for disease control and treatment, the disproportionate role of non-governmental organisations (NGOs), and a warped perception of accountability at different levels. An intricate relation exists between stigma and outcomes of HIV/AIDS control measures, including treatment adherence, and the role of HIV NGOs in Pakistan. In Pakistan's HIV prevention sector, most community work related to HIV and key populations has been delegated to NGOs, which rely mostly on foreign aid and respond to incentives created by international actors. Additionally, NGOs often leverage perceived cultural differences between at-risk groups to secure funding and maintain their position as brokers of funding primarily controlled by international donors.2Qureshi A Stigma and strategy in Pakistan's HIV prevention sector.J R Anthropol Inst. 2022; 28: 1177-1191Crossref Scopus (3) Google Scholar NGOs also reportedly use practices that inadvertently reinforce existing biases.3Bano M Partnerships and the good-governance agenda: improving service delivery through state–NGO collaborations.Voluntas. 2019; 30: 1270-1283Crossref Scopus (19) Google Scholar The pressure to meet deliverables without adequate monitoring further compromises the reliability of the reported key performance indicators.4Farooq LS Beyond good intentions: questioning the "leaving no one behind" agenda in global development, evidence from Pakistan.Community Dev J. 2021; 57: 469-486Crossref Scopus (2) Google Scholar Because the HIV response in Pakistan heavily relies on NGOs and external donor funding, a constrained level of political commitment exists, with a relatively low priority assigned to HIV within the national agenda. Marginalised communities with HIV in Pakistan are less likely to seek health care when needed and, as such, stigma leads to delayed diagnosis and subsequent undetected spread of HIV.5Donnelly LR Bailey L Jessani A Postnikoff J Kerston P Brondani M Stigma experiences in marginalized people living with HIV seeking health services and resources in Canada.J Assoc Nurses AIDS Care. 2016; 27: 768-783Crossref PubMed Scopus (0) Google Scholar There are 74 antiretroviral therapy centres in the country, functioning as easily identifiable, standalone clinics with clearly labelled signage (figure). People using such facilities, and even doctors providing services at these centres, can easily be identified by local community members. The overt lack of integration of HIV care into regular health systems is perpetuating stigma, driving away those who are most in need of screening and treatment, and contributing to the eventual failure of the strategy. This is also an infringement on the confidentiality rights of people using such centres. Given these challenges, an appraisal is needed to review the factors that are hindering the control of HIV/AIDS in Pakistan. Crucial components needed for the HIV continuum of care include addressing high-risk behaviours, instituting preventive measures in key populations, promoting health-seeking behaviours, and integrating services for key populations into general health systems. Appropriate, easily accessible screening and treatment facilities should be made readily available as part of routine medical services. This must be linked with ongoing education of physicians and other health-care workers, community education, and engagement to prevent the escalation of the HIV epidemic in Pakistan. Lastly, for long-term success, it is imperative to explore more sustainable and diversified alternative approaches to over-reliance on NGOs and external funds. We declare no competing interests.