“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2003). Health can be disturbed by disease. People suffer from variety of disease, which not only affect our physical health but also mental health. Considering the significant feature of AIDS is a disease which affects one’s individual life along with society. AIDS is the epidemic diseases affecting both industrialized and developing countries and morbidity and mortality rates of AIDS are gradually increasing. In south East Asia prevalence of AIDS in 2007 was 0.35% and progressively increasing in other countries of south Asia. Pakistan is at high risk for HIV/AIDs epidemic due to several socioeconomic conditions, including illiteracy, unemployment and poverty.
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Furthermore, Pakistan is identified as a low-prevalence, high-risk country for HIV infection. General population prevalence was estimated as 0.1% and high-risk population prevalence as 1-2% (UNAIDS). 96,000 people living with HIV/AIDS in Pakistan, and 5,100 people died of AIDS-related complications. In developing countries around 90% people are suffering from AIDS and incidence rate is provoked by illiteracy, unhealthy sexual practices, lack of medical facilities, use of contaminated syringes and drug injectors (Yousaf, Zia, Babar & Ashraf, 2011). Sex workers and drug injectors are highly vulnerable to HIV due to inadequate knowledge which leads to HIV infection (UNAIDS, 2006). Common transmission of HIV/AIDS is mainly heterosexual is 52.55%, contaminated blood products is 11.73%. Other includes IDU-injecting drug users 2.02%, male-to-male or bisexual relations 4.55%, mother-to-child transmission 2.2% and transmission of undetermined origin 26.9 %. (Bhurgri, 2006).
AIDS is fourth major cause of death. Globally, in December 2007 people living with AIDS were 33.2 million thus morbidity rate was 2.5 million and mortality was 2.1 million (Park, 2009). Likewise, worldwide 16 million people inject drugs and among them 3 million are having HIV. On average, one out of every ten new HIV infections is affected by injecting drug users and in some countries like Eastern Europe and Central Asia over 80 % of all HIV infections is related to drug users. A survey conducted in Lahore and Karachi (March-July 2004) indicated an epidemic of HIV positive among injecting drug users (IDUs) which is 23% out of 402 and man sex with mans which is 4% out of 409 in Karachi (world bank,2006). HIV/AIDS Surveillance Report, Pakistan 2006-07 sexual activities between commercial workers like, FSWs, MSWs, HSWs and IDUs will increase the epidemic potential. In Pakistan, although HIV infection rates among FSWs remain very low, there is evidence of sexual interaction between FSWs and IDUs. Approximately 2.3% of FSWs and 5.7% of MSW and HSWs reported that they are also IDUs (Zaheer et al., 2008). In AKUH 36 cases of AIDS were identified among people of age group of 18-40 years in last six years.
HIV/AIDS was first discovery in 1983 and pathogen involved in the cause of AIDS was HIV-1. Later on in 1986, a second type of virus was discovered HIV-2, which was isolated from HIV patient. Simian immunodeficiency virus (SIV) is originated naturally in a monkey of West African (Sharp & Hahn, 2010). Studies shows the close relation of primary human immunodeficiency virus (HIV-1) and simian immunodeficiency virus which carried by chimpanzee. After comparison, investigators concluded that there must be multiple transmission events from simians to humans (Moore, 2004). In Pakistan, AIDS was firstly detected in 1987 in Lahore. In late 1980s and 1990s, incidences were increased. Generally men were infected while living in or move to abroad and transmit infection to their spouse and it may pass to their children. In 1993, transmission of AIDS through breast feeding was firstly reported in Rawalpindi. During 1990s, HIV/AIDS cases start to appear among commercial sex workers, drug abusers and jail prisoners. During the time period of 2005 to 2007 HIV cases increased from 9% to 15.8% in drug users and more than 6000 cases were reported till 2010 (Ilyas et al., 2001).
Pakistan is a low socioeconomic country with increase in population and unemployment which brings it to a high risk for HIV due to a progressive increase in urbanization and immigration. People live unaccompanied in abroad they try to satisfy their sexual desires by prostitution or engaging in homosexual behaviors. Similarly factors like political instability, War on terror and frequent natural disasters provoke an individual to use drugs as coping mechanism. Research in Pakistan a special Issue of JPMA on HIV/AIDS highlights that commercial sex worker, male transvestites, homosexual men, long distance truckers, sailors, needle sharers, prisoners, deployed army troops and unscreened blood products recipients are high risk group in Pakistan. AIDS in gays and Hijras (homosexuality) being highly stigmatized and religious taboo which are under-reported, so mostly uncovered in various projects on HIV (Altaf, Abbas & Zaheer, 2008).Consequently, condom use is very low (6.7%) among male sex workers and Hijra sex workers (Ahmed et al., 2003). Risk behaviors include sharing of syringes, lack of awareness about blood born infections and due to financial issues or using inject-able drugs prone them to vulnerability. High risk groups can be explained by necessary and sufficient causes. Sufficient causes for HIV transmission comprises of Human Immune Deficiency Virus, which must be present in sufficient quantity and should enter to blood stream. In infectious disease presence of pathogen is necessary. In HIV only one risky behavior like anal intercourse cannot cause HIV infection. Likewise, amount of virus in body fluids determines whether infection has been transferred or not (Card et al., 2008). HIV is present in saliva, sweat, tears, and urine in low amount and in anal secretion virus present moderate amount. While, higher concentration is found in blood and vaginal secretions. Small amount of infected blood, breast milk or semen is enough to get infection. Thus there are multiple causes and risk factors for HIV/AIDS but only HIV virus is necessary cause and other factors like risky behavior consider as sufficient. HIV can be explained from epidemiological triad in which HIV is agent responsible for infection. Nonliving agents include drugs and contaminated syringes. Human being is the host which also includes its characteristics; for instance, sex and life style. Female is at higher risk and those who are living alone and far away from family. Last component of triad includes environmental factors and geographical location also increases risk. Pakistan is sharing border with Afghanistan a country having free trade of drugs. Similarly, social components also determinant increase risk for HIV. Customs like late marriages, practices of premature sex, lack of sex education etc.
In addition, Natural process of diseases is divided into three phases; primary phase, secondary phase and tertiary phase. In primary phase nonspecific symptoms appear. However, in secondary phase is the clinical latency period up to ten years and AIDS become clinically apparent in tertiary phase (Yadav & Sinha, 2006). Clinical progression of AIDS is divided into seven stages. In First stage pathogen enters in the body through infected blood, unsafe sexual behaviors, prenatal transmission (placenta to fetus), and through breast feeding. Second stage is also known as acute/primary HIV infection or acute Seroconversion syndrome. Infection begins from the time of exposure to the appearance of the first sign and symptoms which called as incubation period. It comprises of 2 to 4 weeks but it may exceed to 6 weeks. AIDS is difficult to diagnose because of vague sign and symptoms. Classical sign and symptoms at this stage include lymphadenopathy, fever, rashes, sore throat myalgia and arthralgia. Two diagnostic test HIV RNA and p24 antigen are performed to identify the presence of diseases. The third stage is Seroconversion in which infected individual will be HIV positive and it can be detected by laboratory test. Seroconversion is also called as window period which lies between six months to 10 years. In fourth stage the T helpers cells are reduce in considerable amount it is known as early HIV diseases. Fifth stage is asymptomatic infection in which diseases progress by high level of destruction of T-helper cells. Sixth stage is early symptomatic HIV infection in which sign and symptoms becomes more apparent and severe which are peripheral neuropathy, vaginal candidiasis, leukoplakia and cervical dysplasia. AIDS and advanced HIV infections are the last stages where the CD4 count becomes less than 200cells/mm3 and 50cells/mm3 respectively. In last stages immune gets suppressed and body will be susceptible to multiple diseases like TB, cancers, neurological and infectious diseases, ultimately lead to death within 12 to 18 months (Sankaran, Volkwein & Bonsall, 1999).
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Moreover, National AIDS control programme of Pakistan recommends the major focus on reducing HIV infection among high risk population. The primordial and primary preventive measures for HIV/AIDS, awareness programs through media, religious leaders, health workers to general population by providing teaching on not to share contaminated syringes, using sterile equipment and avoid unsafe sexual practices. Through health promotion it will increases the awareness among individuals and providing specific protection to the risk groups such as IDUs, FSWs, MSMs, HSWs. AIDS among drug injectors are increased in Pakistan because of low level of awareness and non effective rules against the drug users (Ahmed et al.,2003). The appropriate legislation or banning on usage of drugs and its import from neighboring country would be effective strategy. Study further suggests blood transfusion is a risk factor; the primary preventive measure for this could be prohibiting the paid blood donations and promoting screening of blood before transfusion. Financial empowerment of drug users will assist them in returning to the society through provision of occupational skills training and job opportunity. Secondary prevention includes early detection of HIV, so high risk population should be screened for level of p24 antigen and CD4 level in blood, which is raised in primary infection stage. To prevent it from further deterioration provide adequate treatment which comprise of retroviral therapy. According to Lancet (2004) Retroviral therapy is the only supportive treatments for HIV and it helps to suppress the infection. Combination antiretroviral therapies (cART) have significantly improved the life expectancy of HIV infected individual and prevent infections. Secondary prevention will be need between the pathological onset and disease symptoms in the window period. It will decrease the prevalence by reducing the onset of diseases (Ann et al., 2008). Tertiary prevention will help patient to prevent any disabilities and opportunistic bacterial and viral infections in clinical or AIDS stage. Hence, lesser life threatening infections will increase their quality of life. In terminal stage only palliative care is important to avoid disabilities because it suppresses immune system.
In addition, primary health care infrastructure needs to be strengthened to provide better access to AIDS education and counseling. These measures include adequate hospital facilities to deal with the epidemic of AIDS (Semba & Bloem, 2008). Health care professional promotes public health by safe practices e.g. wearing gloves during procedure. Along with patients, staff should also take preventive measures. Pakistani government can play their role by establishment of HIV health care centers or Study center where registry can be done of HIV infected patients, where people can approach for awareness. It will be a supportive step for public education, and reducing stigma against HIV in society.
In conclusion, health comprises of physical, mental and social wellbeing. Various diseases can alter health state. HIV infection is having devastating impact in developing countries. Pakistan is high risk country due to its geographic location, socio-cultural background and Unhealthy sexual practices, lack of medical facilities and illiteracy. IDU’s, FSW, MSW, Arm Forces are high risk population and under-reported. First case in Pakistan was identified in Lahore. In light of web of causation HIV is necessary cause and risky behavior are sufficient causes. AIDS has three phases primary infection phase, secondary latency phase and tertiary phases. In last stage CD4 cell count lessened and patient get susceptible to other diseases. Primary focus is to aware about AIDS high risk population. Secondary level includes screening and ART therapy and tertiary level comprises of preventing spread and managing infections. Center should build for HIV management and program should be run by government for prevention as it is said that prevention is better than cure.
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