Objective

To describe feasibility and results of systematic screening of tuberculosis (TB) patients for HIV.

Design

Cross-sectional study.

Setting

Six selected sentinel sites (public DOTS clinics) in the province of Sindh, Pakistan.

Participants

All TB patients aged 16–60 years registered for treatment from April 2008 to March 2012.

Measurement

Demographic information of registered TB patients, screening for HIV through rapid testing and confirmation by referral lab of Sindh AIDS Control Program, according to national guidelines.

Results

Of a total of 18 461 registered TB patients, 12 882 fulfilled the inclusion criteria and were given education and counselling. Of those counselled 12 552 (97.4%) were screened for HIV using a rapid test. Men made up 48% of the sample and 76.5% of patients had pulmonary TB. Of the total patients tested, 42 (0.34%) were HIV-positive after confirmatory testing at the Sindh AIDS Control Program Laboratory. Prevalence of HIV among male patients was 0.67% whereas prevalence among female patients was 0.03% (p value <0.001). Prevalence of HIV among pulmonary TB patients was 0.29% and among extrapulmonary TB patients was 0.48% (p value=0.09).

Conclusion

In public DOTS clinics in Pakistan it is feasible to test TB patients for HIV. Prevalence of HIV is three times higher among TB patients as compared with the general population in Pakistan. Although the results are not representative of Pakistan or Sindh province they cover a large catchment area and closely match WHO estimate for the country. Routinely screening all TB patients for HIV infection, especially targeting men and ensuring antiretroviral therapy, can significantly improve TB/HIV collaborative activities in Pakistan and identify many cases of HIV, improve health outcomes and save lives.

Objective

To describe the prevalence and predictors of condom use and sexual risk in the male clients of Hijra sex workers (HSWs) in Karachi, Pakistan.

Design

Cross-sectional study.

Setting

Karachi, Pakistan.

Participants

Clients of HSWs were recruited with assistance from HSWs and a non-governmental organisation (NGO) focused on men who have sex with men (MSM) during October–November 2010.

Measurements

The interviewer administered the questionnaire to each participant to solicit information on demographics, HIV/AIDS knowledge/attitudes and sexual risk behaviours/practices, including condom use in the last sexual act with the HSW.

Results

Of the 203 participants, 42.4% reported that they used condoms during their last sexual act with HSW, 40% were married, 18% had ever used drugs or alcohol, and 52% reported also engaging with female sex workers in the last month. Casual HSW clients were more likely to use condoms than regular clients (adjusted OR (AOR), 2.50; 95% CI 1.34 to 4.65), as were persons with a higher education level (AOR 5.8; 95% CI 1.6 to 20.3). Drug/alcohol users and non-users were equally likely to use condoms (AOR 1.11; 95% CI 0.51 to 2.24).

Conclusion

Clients of HSWs in Pakistan are at risk of acquiring HIV/STI infections. Concerted efforts are needed to increase condom use in this key bridge population to curtail the spread of HIV in the general population.

Article summary

Article focus

To determine the prevalence of condom use in regular and casual clients of Hijra sex workers.

Key messages

It is feasible to access hard-to-reach populations.

The intervention programme should also focus on clients.

Strengths and limitations of this study

This is the first study of its kind.

The study involved no HIV testing.

The study gave an incentive to clients and Hijra sex workers for participating in the study.

Background

Surveillance data of Sindh AIDS Control Programme, Pakistan suggest that HIV infection is rapidly increasing among IDUs in Karachi and has reached 9% in 2004–5 indicating that the country has progressed from nascent to concentrated level of HIV epidemic. Findings of 2nd generation surveillance in 2004–5 also indicate 104/395 (26.3%) IDUs HIV positive in the city.

Methods

We conducted a cross sectional study among registered IDUs of a needle exchange and harm reduction programme in Karachi, Pakistan. A total of 161 IDUs were included in the study between October–November 2003. A detailed questionnaire was implemented and blood samples were collected for HIV, hepatitis B & C and syphilis. HIV, hepatitis B and C antibody tests were performed using Enzyme Linked Immunosorbent Assay (ELISA) method. Syphilis tests (RPR & TPHA) were performed on Randox kit.

Besides calculating frequencies univariate analysis was performed using t tests for continuous variables as age, age at first intercourse and average age of initiation of addiction and chi square for categorical variables like paid for sex or not to identify risk factors for hepatitis B and C and syphilis.

Results

Average age of IDU was 35.9 years and average age of initiation of drugs was 15.9 years. Number of drug injections per day was 2.3. Shooting drugs in group sharing syringes was reported by 128 (79.5%) IDUs. Over half 94 (58.3%) reported paying for sex and 64% reported never using a condom. Commercial selling of blood was reported by 44 (28%). 1 of 161 was HIV positive (0.6%). The prevalence of hepatitis B was 12 (7.5%), hepatitis C 151 (94.3%) and syphilis 21 (13.1%). IDUs who were hepatitis C positive were more likely to start sexual activity at an earlier age and had never used condoms. Similarly IDUs who were hepatitis B positive were more likely to belong to a younger age group. Syphilis positive IDUs were more likely to have paid for sex and had never used a condom.

Conclusion

Prudent measures such as access to sterile syringes, rehabilitation and opiate substitution therapies are required to reduce high risk behaviors of IDUs in Pakistan.