HIV Interventions forHIV Interventions for IDUs in Pakistan:IDUs in Pakistan:

Insights from Triangulation of Program,Insights from Triangulation of Program, Field and Surveillance Data 

Adnan A Khan MBBS MSAdnan A. Khan, MBBS, MS.Ministry of Health, Pakistan

HIV in PakistanHIV in Pakistan

• Mainly among IDUs and to some extent migrant laborg

• Around 80‐100,000 street based IDUs with 20% HIV prevalence20% HIV prevalence

• Around 70,000 each of M/FSWs

• Around 2‐5% HIV prevalence among MSWs

U d t t bl HIV FSW• Undetectable HIV among FSWs

• Asian Epidemic Model

HIV in Pakistan: Timeline

40

HASP round 2RT/STI Study 2

30

40EACP startedHASP pilot

RT/STI Study 1

HASP round 1Other studies

/ y

30 RT/STI Study 1

Larkana incidentNACP 

IDUs

First case

20

MSWsHIV Care started

incidentFormed

ANCcase detected

10 MSWs?

startedANC Study

General IDUs

87 89 94 01 03 04 05 07

PopulationIDUs

06

198

198

199

200

200

200

200

200

200

HIV Response in PakistanHIV Response in Pakistan

Funding :

• Enhanced HIV/AIDS Control Program 2004 ‐ 9

• Global Fund grant 2004 – 8

• Other small scale initiativesOther small scale initiatives

HIV Response in PakistanHIV Response in Pakistan

The Enhanced AIDS Control Program 2003‐8

• USD 75 millionUSD 75 million

• Aimed at IDUs, FSWs, MSWs

• Some truckers

• Mass media campaignMass media campaign

• HIV treatment

• STI Care

• PPTCT• PPTCT

Enhanced HIV/AIDS Control ProgramEnhanced HIV/AIDS Control Program

• Targeted interventions for risk groups – 25% of the budgetg

• HIV treatment – Rs. 78 Million

M di C i f h l l i• Media Campaign for the general population –Rs. 720 Million

Interventions for IDUs/SWsInterventions for IDUs/SWsCities Contractor NGO

Karachi 1 Nai Zindagi*Karachi 2 Pakistan SocietyKarachi 3 Al NijaatLahore Nai ZindagiFaisalabad Nai ZindagiSargodha Nai ZindagiSialkot Nai ZindagiPeshawar Dost Foundation

dQuetta Legend* The NGO stopped operations since February 2006

Source: The World Bank Aide Memoire for HIV Financing Nov 2007Source: The World Bank Aide Memoire for HIV Financing, Nov 2007

Measuring EffectivenessMeasuring Effectiveness

Tools available

• Cross‐sectional surveys

• Incidence Monitoring

• Coverage• Coverage

DesignDesign

1. Cross‐sectional comparison of intervention and non‐intervention cities

2 In time comparison of2. In‐time comparison of intervention cities

3. Measurement of coverage

4 Cost effectiveness analysis4. Cost effectiveness analysis

Methods: Data SourcesMethods: Data Sources

• HIV/AIDS Surveillance Project (HASP)

• Research StudiesResearch Studies

• HIV program data

• Field interviews

Methods: ComparisonsMethods: Comparisons

• Behaviors: Sexual and injecting

• PrevalencePrevalence

• Knowledge

Methods: Coverage MeasurementMethods: Coverage Measurement

• Denominator: Demand for syringes in the city

• Calculated fromCalculated from

• Number of IDUs (HASP)

• Registered clients of NGOs• Mean Injecting frequencyMean Injecting frequency

• Numerator: Syringes provided

Coverage MeasurementCoverage Measurement

Coverage = Supply of syringes

Demand for syringesDemand for syringes

Demand for Syringes = Daily injections by IDUs xDemand for Syringes = Daily injections by IDUs x 75 x 0.5 x number of IDUs

Results 1

Comparison of Intervention andComparison of Intervention and Non‐intervention citiesNon intervention cities

IDUsInterventi

Interventi +

ption ‐ tion +

HIV St t 10% 23% 0 001HIV Status 10% 23% <0.001

( )How long you have been injecting drugs (years) 4 5 0.026

Usual average injections daily (median) 2 2 0.046

Always used a new syringe when injecting in the 27% 59% <0.001

past month27% 59% 0.001

Used a "used needle" with last injection 40% 12% <0.001

Did you try and clean the last old needle you used 63% 85% <0.001

Got new Syringe/ Needle from NGO 9% 59% <0.001y g /

Results 2:Results 2:

Changes over time in 

Intervention CitiesIntervention Cities

IDUs: Karachi 2IDUs: Karachi 2

200 000

250,000 Syringes Distributed per quarter

150,000

200,000

ring

es Anticipated need for Syringes (by registered 

100,000

Sy clients) (25 days a month)Anticipated need for 

50,000

pSyringes (by HASP targets)32%

0

1 2 3 4 5 6 7 8 9 10 11 12

Anticipated syringe need (based on HASP behavioral data NGO 1 2 3 4 5 6 7 8 9 10 11 12

Quarter Targets)

CoverageCoverage

City CoverageKarachi 2 39%Karachi 2 39%Karachi 3 32%Lahore  47%Sargodha 61%Sialkot 40%Sialkot 40%Faisalabad 70%

IDUs: Karachi 3IDUs: Karachi 3

39%

IDUs: LahoreIDUs: Lahore

47%

IDUs: SargodhaIDUs: Sargodha

61%

IDUs: SialkotIDUs: Sialkot

40%

IDUs: FaisalabadIDUs: Faisalabad

70%

Nationwide Coverage: IDUsgIDUs

HASP projected IDUs

Actual client registrations by 

NGOs

Percent registered Coverage

Large Urban Centers

Punjab 22 011 14 989 68% 36%Punjab 22,011 14,989 68% 36%Sind 13,750 5,651 41% 16%NWFP 339 125 37% 3%Balochistan 221 550 249% 205%

Nationwide 36,321 21,315 59% 30%

All urban and rural

Punjab 57,353 14,989 26% 14%Sind 23,818 5,651 24% 9%NWFP 1,322 125 9% 1%B l hi 734 550 75% 62%Balochistan 734 550 75% 62%

Nationwide 83,227 21,315 26% 13%

Other findingsOther findings

Outreach: 95‐150 clients per ORW

Voluntary Counseling and Testing:Voluntary Counseling and Testing:

• NZ (IDUs, Punjab) use rapid tests. All others send out.

• Client loss with delaysClient loss with delays

• No single NGO has >2,500 tests

Costs

Total Annual t Adj t d fName of Contractor

Total Clients served

cost per client in

USD

Adjusted for performance

USD

Ideal: 205Nai Zindagi(4 cities) 14,989 403 460( )Pakistan Society(K hi 2) 2 712 31 278(Karachi-2) 2,712 31 278

Al-NijaatAl-Nijaat(Karachi 3) 2,939 37 337

LimitationsLimitations

• Estimates of IDUs vary between sources

• Used external sources: HASP, NGOs. Neither sources are independently validated

• Used surrogates, as data about actual client contactUsed surrogates, as data about actual client contact are not available

• Assumption about a client using a syringe twice must• Assumption about a client using a syringe twice must be explored and accurately documented

• HASP data used (Rd 2) were 2 years old behaviors• HASP data used (Rd 2) were 2 years old, behaviors may have changed

• HASP used different sampling methodology in each of the round

ConclusionsConclusions

• IDUs interventions are moderately successful

• Room to improve costs and coverageRoom to improve costs and coverage

• VCT and outreach should be enhanced

• New cities to be covered

• Leaner management structures neededLeaner management structures needed

• Systematic assessment of results should be routine and be used to guide implementation

AcknowledgementsAcknowledgementsThe World Bank The Punjab AIDS Control Programme

Dr. Shahnaz KaziDr. Benjamin LoevinsohnDr. Agnes Couffinahl

Dr. Ali RazaqueDr. Mehmood AkhtarDr. Nadeem Zaka

The National AIDS Control Programme The Sindh AIDS Control Programme

Dr. Hasan Abbas ZaheerDr. Ayesha Khan

Dr. Nasir JalbaniDr. Qamar AbbassMr. Moosa Kazi

Salman ul Hasan Qureshi

The HASP team The NWFP AIDS Control ProgrammeThe HASP team

All HIV implementing NGOs

Dr Chris Archibald (PHAC)

Dr. Roohullah JanDr. Rajwal KhanDr Nasreen AftabDr. Chris Archibald (PHAC)

Dr. James Blanchard (U of Manitoba)

Dr. Nasreen Aftab