The document provides information about HIV/AIDS in Pakistan, including: 1) It discusses the objectives and infrastructure of the Enhanced Sindh AIDS Control Program, including voluntary counseling and testing centers, STI clinics, and PPTCT centers. 2) It provides a brief history of HIV, noting it originated from chimpanzees and was first identified in the US in 1981. HIV attacks and destroys CD4 cells, eventually causing AIDS. 3) It discusses HIV transmission, noting the major routes are sexual contact, exposure to infected blood or blood products, and from mother to child during pregnancy, birth, or breastfeeding.

1. PAKISTAN Presenter Dr. M. MUNAWAR KHAN PROVINCIAL BCC COORDINATOR ENHANCED SINDH AIDS CONTROL PROGRAM What is HIV/AIDS ?

4. ENHANCED HIV/AIDS CONTROL PROGRAM SINDH

5. Sindh AIDS Control Program Objectives To create awareness of the seriousness of the disease Ensure that people of Sindh are equipped with knowledge and tools to protect themselves Reduce transmission of HIV and other STI infections through blood and blood products In case of infection, the patient should be encouraged to seek treatment

6. Infra Structure and Services on Ground Provincial Implementation UNIT (PIU) At I. I Depot, Rafique Shaheed Road near JPMC. Referral Lab Established for laboratory diagnosis and confirmation of HIV/AIDS Cases & Sexually Transmitted Infections. Voluntary Counseling & Testing centers 21 VCT Centers have been Established for screening of HIV/AIDS cases STIs clinics 46 STIs Clinics have been Established at teaching and DHQ hospitals for management of STI,s Establishment of Resource Center With Facilities of Digital Library. For trainees and projects staff PPTCT Centers 03 ( Prevention of Parents to Chid Transmission )

7. Tertiary Hospitals: PIMS- Islamabad HMC- Peshawar Lady Wallingdon- Lahore Services- Lahore Civil- Karachi Qatar- Karachi Shaikh Zaid Hospital Larkano Sindamon- Quetta (nonfunctional) District Headquarter Hospitals: DHQ Hospital, Gujrat DHQ Hospital, DG Khan PPTCT Centers of Pakistan

8. Origin of HIV

9. African Simean [Green] Chimpanzee

10. HIV came from a similar virus found in chimpanzees - SIV. HIV probably entered the United States around 1970 CDC in 1981 noticed unusual clusters of Kaposi’s sarcoma in gay men in NY and San Francisco, which led to the disease to be called GRID (Gay Related Immune Deficiency). By 1982 the disease was apparent in heterosexuals and was renamed AIDS (Acquired Immune Deficiency).

11. 1981 History collected by Dr MZ 8 cases of KS among young gay men June 5, 1981: 5 cases of PCP( Pneumocystis Pneumonia ) in gay men Los Angeles, San Francisco and New York, who had developed PCP ... from UCLA (MMWR)

12. I n the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal infection. Morbidity and Mortality Weekly Report (MMWR) MMWR SEARCH

13. 2006 History US National Institutes of Health revealed the results of two African trials of male circumcision as an HIV prevention method with clear evidence that the intervention reduced HIV transmission by around 50%. + The WHO and other organizations suggested they would soon begin promoting male circumcision in areas with severe HIV epidemics. collected by Dr MZ

14. Global summary of the AIDS epidemic  2009 33.3 million 30.8 million 15.9 million 2.5 million 2.6 million 2.2 million 370 000 1.8 million 1.6 million 260 000 Number of people living with HIV People newly infected with HIV in 2009 AIDS deaths in 2009 Total Adults Women Children (<15 years) Total Adults Children (<15 years) Total Adults Children (<15 years)

15. Over 7000 new HIV infections a day in 2009 About 97% are in low and middle income countries About 1000 are in children under 15 years of age About 6000 are in adults aged 15 years and older, of whom: ─ almost 51% are among women ─ about 41% are among young people (15-24)

17. HIV/AIDS in Pakistan Pakistan is going through a transition of the HIV epidemic; from a low Prevalence state to a concentrated epidemic. Although the estimated prevalence among the general population is less than 0.1% in the country, Recent surveillance results clearly indicate that the epidemic is becoming established among certain high risk groups (HRGs).

18. Pakistan’s HIV epidemic At present the most prominent face of Pakistan’s HIV epidemic are the IDUs. In this regards, Pakistan is following the Asian Epidemic Model , where the HIV epidemic first establishes among IDUs and then spreads to the rest of the population via sex workers who have sexual contact with IDUs.

19. SUGGESTIVE HISTORY & RISK FACTORS RISK FACTORS/RISK BEHAVIOURS People with multiple sexual partners People with recent or prior STDs Commercial sex workers & their partners Homosexuals Travelers to high prevalence areas Sexually active injection drug users Sexual partners of at risk persons Recipients of blood products prior to HIV screening Children born to HIV positive mothers

20. A combination of risk factors is currently putting Pakistan at serious risk of further transmission from high to low risk groups through bridging populations. Pakistan’s HIV epidemic

21. Example of high risk sexual networks in a population FSW Male Clients IDU General Population Women MSW

23. HISTORY OF HIV IN PAKISTAN 1986 – An African Sailor Died in Karachi 1987 – First Pakistani Citizen Diagnosed with AIDS in Lahore 1987 – First Husband-Wife-Child transmission of HIV occurred in Rawalpindi 1993 – First Breastfed Baby gets AIDS in Karachi 2003 First outbreak among Injecting Drug Users was identified in Larkana

24. HIV & AIDS in Pakistan (2 nd Quarter 2010) Total Estimated Cases = 106000 Total reported HIV & AIDS cases in the country are = 7574 HIV Positive – 7049 AIDS Cases – 525

25. SINDH Upto September 30,2011 TOTAL CASES = 4325 HIV Asymptomatic Cases= 4130 Male = 3885 94.07 % Child = 23 0.56% Female = 205 4.96% Child = 17 0.41% AIDS CASES = 195 Male = 164 (84.10 %) Child = 01 (0.51%) Female = 29 (14.87) Child = 01 (0.51%)

26. DEATH CASES TILL 30 th September 2011 DEATH = 140 Male = 122 87.14% Child = 02 1.43% Female = 10 7.14% Child = 06 4.29%

27. Sindh is in the concentrated phase of epidemic among : IDU’s = 27% Hijra Sex workers =15.45%

28. HIV epidemic is still considered ‘low’ or ‘concentrated,’ confined mainly to individuals who engage in high risk behaviors, An epidemic is considered ‘ concentrated ’ when less than one per cent of the general population but more than five per cent of any ‘high risk’ group are HIV-positive An epidemic is considered ‘ generalized’ when more than one per cent of the population is HIV-positive.

29. AIDS

30. H I V Human Immunodeficiency Virus

31. HIV ? HIV is different from most other viruses because it attacks the immune system The immune system gives our bodies the ability to fight infections. HIV finds and destroys a type of white blood cell WBC (T cells or CD4 cells) that the immune system must have to fight disease. People can live a long healthy life with HIV without symptoms, even without medications. Once the immune system begins to break down over time, and the person develops more symptoms, This often means they have progressed to AIDS.

32. Caused by immune deficiency virus HIV-1 HIV-2

33. Genetic Subtypes of HIV Groups : HIV 1 , HIV 2 Genetic subtypes : Groups : HIV 1 - M(main),O(outlier),N (new) Subtypes(clades) M(11 subtypes A-I,CRF) HIV 2 —Six subtypes A-F

34. DIFFERENCE B/W HIV-1 & HIV-2 HIV-1 and HIV-2 are closely related, they are thought to have jumped from primates to humans at different times (and from different species). HIV-1 is more easily transmitted, it also spreads more readily and therefore accounts for the vast majority of global HIV infections. HIV-2, is much less transmittable, is largely confined to West Africa (where it is thought to have originated) and to West African migrant communities in Europe.

35. DIFFERENCE B/W HIV-1 & HIV-2 HIV-1 also mutates more efficiently that HIV-2 and generally progresses to AIDS at a significantly faster rate than HIV-2 does. Also, HIV-2 has Vpr and Vpx proteins. HIV-1 has only Vpr. Differences between these proteins are actually on research.

36. HIV-1 and HIV-2 Infections HIV-2 has the same genetic organization as HIV-1 but there are significant differences in the envelope glycoprotein Similar diseases associated with both HIV-1 and HIV-2 but most west Africans remain asymptomatic Progression from HIV to AIDS is faster in HIV-1 as compared to HIV-2, either it is less pathogenic or it has a long period of latency HIV-2 infected children have far better survival rates

37. VIROLOGY / LIFE CYCLE HIV is a retrovirus belonging to the family of Lentivirus Able to use the RNA and the host DNA to make viral DNA Long incubation period/Clinical latency

38. THE HIV LIFE CYCLE CONTINUOUS VIRAL REPLICATION LEADING TO IMMUNODEFICIENCY IS THE HALLMARK OF THE DISEASE!!

39. The Immune System T Cells (CD4 Cells) = Part of body’s immune system ! CD4 The average person has between 800 & 1500 CD4 cells per cubic millimetre of blood The immune system helps fight diseases Disease CD4 Disease KILLS DISEASE IMMUNE SYSTEM ATTACKS DISEASE

40. HIV and the Immune System When HIV enters the body it must enter a cell to live and reproduce. The HIV virus attacks CD4 cells, eventually killing them The newly produced HIV then moves into new CD4 cells and infects them. The body’s immune system tries to replace the lost CD4 cells, but over time it is unable to keep these levels up. HIV HIV HIV HIV CD4 HIV HIV Enters CD4 Cells HIV Replicates Kills CD4 Cells CD4

41. HIV-Infected T-Cell HIV Virus T-Cell HIV Infected T-Cell New HIV Virus

42. VIROLOGY gp 120 & gp 41 have the major role to recognize CD 4 cells thus promoting attachment

43. HIV Replication HIV is a retrovirus . Viral envelope protein gp120 and gp41 attach to the CD4 antigen complex on host cells CD4 found on T helper lymphocyte,B lymphocytes, monocytes and tissue macrophages. HIV uses RT to convert RNA to DNA HIV DNA enters nucleus of CD4 cell and integrates into host DNA. HIV DNA instructs cell to make copies of original virus. New virus particles are assembled and leave cell, ready to infect other CD4 cells.

45. Reverse Transcriptase Inhibitor (red) Protease Inhibitors Viral RNA yellow , DNA blue Attachmen t Entry of the Viral RNA Reverse Transcription Translation: RNA -> Proteins Viral Protease Assembly and Budding Integration of Viral DNA Transcription: Back to RNA

47. HIV Transmission HIV enters the bloodstream through: Open Cuts Breaks in the skin Mucous membranes Direct injection

48. HIV Modes of Transmission Sexual Infected blood and blood products Mother to Child

49. HIV Modes of Transmission Cont’d… 1. Sexual: Through sex with infected man or woman. Transmit by Hetrosexual & Homosexual and Bisexual Practice Ulcerative STIs increases the risk of infection several folds

50. 2. Infected blood and blood products Contaminated Blood/Blood Products transfer Organ/Tissue Transplants Use of Contaminated Syringes and Needles Tattooing Ear piercing etc. HIV Modes of Transmission Cont’d…

51. HIV Modes of Transmission Cont’d… 3. From mother to child (Vertical) Pregnancy Delivery Lactation

52. HIV/AIDS Interflow Communications

53. Press ad Option 1

54. How you catch up HIV? The virus spread from human to human by body fluids : Blood, Semen, female vagina fluids and mother milk. HIV do spread in full sexual Intercourse that include penetration to female vagina or the rectum without the use of Condom, and that’s because its lives within the human fluids, as mention above. HIV also do spread by using common needle, because AIDS lives in the blood, due to that fact, drugs addict are extremely vulnerable for HIV infection. HIV is spreading by a breast feeding, because it can live within mother milks.

55. HIV Transmission cont’d… Common fluids that are a means of transmission: Blood Semen Vaginal Secretions Breast Milk Saliva

56. ? How can you get HIV? BREAST MILK VAGINAL SECRETIONS BLOOD SEMEN CERVICAL SECRETIONS 2. Through these acts: H INFECTED MOTHER: DURING 1. PREGNANCY 2. BIRTH 3. BREAST FEEDING UNPROTECTED PENETRATIVE INTERCOURSE (HOMOSEXUAL OR HETEROSEXUAL) WITH SOMEONE WHO IS INFECTED 1. INJECTION OR TRANSFUSION OF INFECTED BLOOD / BLOOD PRODUCTS 2. SHARING UNSTERILISED NEEDLES WITH SOMEONE WHO IS INFECTED 1. Through these bodily fluids

57. HIV in Body Fluids Semen 11,000 Vaginal Fluid 7,000 Blood 18,000 Amniotic Fluid 4,000 Saliva 1 Average number of HIV particles in 1 ml of these body fluids

58. TRANSMISSION RISK AFTER EXPOSURE 95% for blood and blood products 15-40% for vertical transmission 0.5% -1.0% for injection drug use 0.2-0.5% for for genital mucous membranes < 0.1% for non genital mucous membranes Needle stick injury : 1 in 300 World wide major route of transmission Heterosexual(70%) Transmission

59. Estimated PPTCT Rates Without intervention During pregnancy 5–10% During labour and delivery About 15% During breastfeeding 5-20% MTCT infection rates = up to 40%

60. HIV Routes of Transmission Sexual Contact: Male-to-male Male-to-female or vice versa Female-to-female Blood Exposure: Injecting drug use/needle sharing Occupational exposure Transfusion of blood products Perinatal: Transmission from mother to baby Pregnancy, delivery and breastfeeding

61. HIV Infection and Antibody Response Infection Occurs AIDS Symptoms ---Initial Stage---- ---------------Intermediate or Latent Stage-------------- ---Illness Stage--- Flu-like Symptoms Or No Symptoms Symptom-free < ---- ----

62. Natural History of HIV Infection

63. Window Period This is the period of time after becoming infected when an HIV test is negative 90 percent of cases test positive within three months of exposure 10 percent of cases test positive within three to six months of exposure

64. Infections in relation to CD4 + cell count Herpes Zoster Tuberculosis Oral Candidiasis Esophageal Candidiasis Mucocutaneous herpes Time AIDS 400 300 200 100 50 PCP Toxoplasmosis Cryptococcosis (Mycobacterium avium complex ) MAC (Cytomegalovirus) CMV (Progressive Multifocal Leuko encephalopathy) PML Cryptosporiodiosis

65. AIDS A I D S Acquired Immunity Deficiency Syndrome It destroys the immune system of infected person.

66. After HIV infection (without ARV) Most will develop AIDS 8-10 years later 5-10% will develop AIDS first few years 5-10% will not progress to AIDS for 15 or more years Evaluation

67. HIV Risk Reduction Avoid unprotected sexual contact Use barriers such as condoms Limit multiple partners by maintaining a long-term relationship with one person

68. Infectious Aids can’t be spread in a full sexual intercourse with condom because the condom prevents infected body fluids.

69. How you watch out? Using condom every time you are making an intercourse. Aids have not yet come with vaccine or remedies that bring for a recovery. Condom is the only tool for preventing infection with AIDS during an intercourse. Those are the facts, this is your life, think good and decide how you want to behave.

70. HIV Risk Reduction Cont’d… Condoms Using condoms is not 100 percent effective in preventing transmission of sexually transmitted infections including HIV Condoms = Safer sex Condoms ≠ Safe sex

71. HIV Risk Reduction Cont’d… Condom Use Should be used consistently and correctly Should be the responsibility of both partners for the protection of both partners Male and female condoms are available

72. Female initiated methods of prevention Female condoms : 97% effective yet currently only manufactured by one company and too expensive Microbicides : gel, film, sponge, lubricant or suppository. Still in development User controlled, protection against HIV/STIs, could be available in contraceptive and non-contraceptive forms. Researchers predict a microbicide that is only 60% effective could prevent more than 2.5 million infections within three years of its introduction. Currently in clinical trials and may be available over the counter within 5-7 years

73. Press ad Option 3

74. HIV Risk Reduction Cont’d… Avoid drug and alcohol use to maintain good judgment Don’t share needles used by others for: Drugs Tattoos Body piercing Make sure GP is using a new syringe Avoid exposure to blood products

75. Drugs Alcohol and Aids What the connection between Drugs and Alcohol? Alcohol and drugs causing you for misjudgment, so if you drunk you can,t better follow the rules of safe sex, and for drugs injections, can transpose the virus.

76. People Infected with HIV Can look healthy Can be unaware of their infection Can live long productive lives when their HIV infection is managed Can infect people when they engage in high-risk behavior

77. How you know? You can’t identify a person who carry HIV and in most cases, he/she himself doesn’t know about it . You can found out the virus only in HIV tests. A person can carry the virus for many years, he can be seen, feel and function as usual,. Don’t hope from your partner to tell you , that he/she carry the HIV virus. Because most people living with the virus are feared from rejection and anger, even though you love each other. The responsibility defending your health is only in your hands!

78. HIV Exposure and Infection Some people have had multiple exposures without becoming infected Some people have been exposed one time and become infected

79. Once a person is infected s/he is always infected Medications are available to prolong life but they do not cure the disease Those who are infected are capable of infecting others without having symptoms or knowing of the infection HIV AIDS

80. Suggested tips To reduce the risk you have to… Avoiding from ejaculation in your mouth Avoiding sucking woman sexual organ during period. Avoiding from swallowing female secreting Make sure no active herpes wounds or others wounds Suggested not to brush your teeth two hours, because of gums sensitivity

81. Not Transmitted infections Aids doesn’t Spread in a hand shaking, because the virus doesn’t live in air or on skin. Aids doesn’t spread in kiss, because in the spittle they are enzymes that neutralized the virus.

82. infectious Aids doesn’t spread by drinking from a the same cup, because it can’t live in air or spittle.

83. Infectious Aids doesn’t spread by a mosquito bite because mosquito can’t carry the human virus of HIV

84. HIV is NOT Transmitted via Casual contact Tears, sweat and saliva Coughing and sneezing Not transmitted via mosquitoes

85. HIV DOES NOT SPREAD IN THESE WAYS

86. Press ad Option 4

87. Challenges Break the silence on HIV and AIDS End stigmatization and discrimination of PLWHA

88. Facts about AIDS No Curative Treatment available. No Vaccine. BUT IT CAN BE PREVENTED

89. Questions are Welcomed if ask

90. Thank you