What lies behind the spread of HIV in Larkana

An HIV test kit | Fahim Siddiqui, White Star

Abid Ali’s eight-month-old son fell ill in April this year. He took him to a local doctor, Muzaffar Ghanghro, in his home town of Ratodero in Larkana district. The doctor was known to understand children’s ailments well. More importantly for poor peasant families living in the town, he charged only 30 rupees for examining a child. By some local accounts, he treated as many as 100 patients each day.

Ali says Ghanghro gave his son many intravenous drips but his condition continued to worsen. So, he says, he took the child to some other doctors in the town. One of them, Imran Akbar Arbani, suggested that the diagnosis of his ailment required blood tests, including those for human immunodeficiency virus, or HIV, that destroys certain cells in human immune system which fight illnesses and infection. The test reports showed Ali’s son to be carrying the virus.

There is no cure for HIV but its spreads within a patient’s body can be managed and controlled with medication. If diagnosed early and treated properly, HIV patients can live as long as any other person but leaving the virus untreated or treating it with wrong medication allows it to produce acquired immunodeficiency syndrome, or AIDS, among its carriers. A patient of AIDS, which is also regarded as the third stage of HIV, gets what in medical jargon is called “opportunistic infections” or some other specific cancers which no treatment can contain, let alone heal. After reaching this stage, a patient usually does not have more than two years to live.

Ali’s son never reached HIV’s third stage but he still did not survive and died within days after his blood test was conducted.

Many other children in Ratodero were being identified as HIV carriers around the same time. Another 11 of them would die within the next month or so.

Almost all of them had been treated at Ghanghro’s clinic at one point or another. Many parents who would take their children to him have reported that he was very careless in handling his patients. “I would give him a new syringe every time I took my son to his clinic but I noticed that he always put it on his work table and used another syringe to administer an injection to my child,” says the father of a two-year-old HIV carrier. “He would also administer an intravenous drip to three to four children simultaneously from the same bottle,” says the worried father.

Ghanghro’s work table was always in a mess, say many local residents who have visited his clinic. “It was always dotted with blood drops,” says the father of an 18-month-old HIV-infected girl. The doctor would place syringes, cannulas and drip sets on the same table without ever disinfecting them.

When representatives of the Sindh healthcare commission, along with the officials of Larkana’s district administration, visited Ghanghro’s clinic on April 29, they found that he was applying the same syringe to give injections to several children. His clinic was immediately sealed.

A police team that later inspected the clinic also reported that “there was no syringe cutter available” there. This, their report stated, “shows that [the] patients were being treated [by Ghanghro] without applying safety measures.”

He was arrested on April 30 — initially under the charge of spreading HIV deliberately. A subsequent police investigation has cleared him of that charge but he is still being accused of criminal negligence.

To his own surprise, Ghanghro himself has also been found to be an HIV carrier. This was revealed after his blood tests were conducted in custody. Talking briefly to the media at the time of his arrest, he claimed to have never known that he was infected by the virus.

That HIV was spreading in Ratodero was first noticed by Arbani earlier this year. When he realised that the condition of a number of children he was treating was not improving, he ran HIV tests on two of them. Both turned out to be infected by the virus. He then tested several other children and found most of them to be carrying HIV.

His findings were shared by the parents of an HIV-infected child on social media on April 23. The news media immediately flooded Ratodero — followed soon by a Sindh AIDS Control Programme team that set up an HIV screening camp on April 25 inside the town’s government hospital.

Since then, working six days a week, technicians and doctors at the camp have been using what in healthcare terminology is known as rapid diagnostic test to screen the local population for HIV and AIDS. This type of test can be conducted in healthcare facilities with no sophisticated equipment and is useful in preliminary screenings or emergency situations.

Over the last month or so, more than 21,000 people have been tested at the camp. “Out of these, 681 have been found to be infected with HIV,” says Dr Sikander Memon who is working with the Sindh AIDS Control Programme.

Among these HIV carriers, 380 are children aged between two and five. The second largest group of them, consisting of 127 patients, is aged between six and 15. Another 55 patients are less than a year old while 104 others are aged between 15 and 45. The incidence of the disease is the lowest among those above the age of 45. Only 15 local HIV carriers, as per the latest screening, belong to this age group.
Another important result of these tests, specifically from the perspective of treatment, is that none of the 681 people has been found to be an AIDS patient, says Memon.

Those found to be the carriers of HIV are sent to Larkana city for further testing and treatment — adult men and women to Larkana Civil Hospital, pregnant women to Sheikh Zayed Women’s Hospital and young ones to a hospital which only treats children. At all the three facilities, the patients get free medicine.

Arbani is not entirely satisfied with this arrangement. He complains the tests being conducted at the screening camp are not always perfect. Seven people under his treatment have already been diagnosed to have HIV by various laboratories but, he alleges, their blood tests conducted at the camp show them to be free of the virus. “Either their kits are faulty or their technicians are making mistakes while conducting the tests,” he says. “Declaring people HIV-free through such tests could be dangerous,” he says.

A clerk at an HIV screening camp in Ratodero | Fahim Siddiqui, White Star

Officials of the Sindh AIDS Control Programme dismiss his misgivings as scaremongering. They insist their equipment and staff are both well-suited for conducting the tests. “Our staff is well trained and we are using testing kits recommended by the World Health Organization. There is no chance of any error in the tests we are conducting,” says Dr Hola Ram, a representative of the Sindh AIDS Control Programme.

A 12-year-old girl burst into tears when she was separated from others at the screening camp on a recent day in May. Her preliminary blood test had shown that she could be carrying HIV. Now she was required to undergo another test to verify, or reject, that indication. She continued to cry while the second test was being performed. It proved that she was infected with HIV.

The finding explained nothing to her widowed mother who did not understand what kind of disease her daughter had contracted. She only knew that her little girl was suffering from “some dangerous” ailment. Another woman at the camp, too, exhibited the same level of ignorance about HIV.

Same is the case with most local residents in Ratodero. They have next to no understanding about HIV. They do not know what causes it, how it spreads, what it does to those infected with it and what possibilities are there to treat it.

Ignorance, uncertainty and fear, indeed, were the most noticeable feelings among all those who were waiting at the screening camp that day to get tested. A few women could be seen praying and reciting verses from the Quran. As the results arrived, those found to be carrying HIV – or their parents if they happened to be young children – would start grieving immediately. Those found to be free of the virus would hug and congratulate each other.

“I was very scared when I came here,” said 19-year-old Rahmat Jakhra who arrived at the camp along with six other family members, including children. “Thank God that none of us have the disease,” she said.

HIV is an infectious disease. It usually spreads via blood – including through used syringes – as well as with unsafe sexual intercourse. The rate of its spread from parents to children, according to Memon, is negligibly low in Ratodero. Such transmission has been found only in six per cent of all the cases so far examined at the screening camp, he says.

Women mostly get HIV from their husbands, says Dr Anila Isran who is also working with the Sindh AIDS Control Programme. Some of them also get infected through unscreened blood transfusions, she adds. Four pregnant women have been found to be HIV-infected so far in the ongoing screening in Ratodero. The chances of the virus getting transmitted to their babies can be minimised through medication. As Anila says, since June 2011, she has treated 96 pregnant women from across Larkana district who were diagnosed with HIV but the virus was not transmitted to their babies in any of those cases.

The number cited by her also suggests something else: the district had many HIV patients even before the current outbreak of virus in Ratodero.

Larkana, in fact, has had the second highest incidence of HIV and AIDS in the whole of Sindh province — after Karachi. A total of 2,016 HIV carriers and five AIDS patients have been registered in the district between the start of 1996 and March 31, 2019. For Karachi, the registered number of those suffering from HIV and AIDS during the same period is 11,282 and 78 respectively.

Most of those infected with HIV and suffering from AIDS in Larkana are either sex workers or drug users. The data collected by Mehran Welfare Trust, a non-governmental organisation, states that the district has 200-250 transgender sex workers, 200 male sex workers, 100 female sex workers and 400-500 drug users who inject themselves with used syringes on a regular basis. (These numbers were gathered in 2014 as part of a survey overseen by the National Aids Control Programme.)

Out of these, 15 per cent transgender sex workers and 18 per cent drug-addicts using second-hand syringes are either HIV-infected or they suffer from AIDS, says Panjal Sangi who works for the Mehran Welfare Trust. Only two or three per cent male prostitutes and one or two per cent female sex workers have been found to be HIV carriers, he says.

These statistics suggest that used syringes are the biggest disseminators of the virus in the district. This has been only further proven by the fact that a vast majority of HIV-infected children in Ratodero got injections with such syringes at Ghangharo’s clinic.

Local administration, therefore, has started a special drive to put an end to the use of second-hand syringes. Administrative measures have been initiated on widespread complaints that a large number of local quacks, who are operating as doctors, often give injections with used syringes. So far, according to Memon, action has been taken against 161 quacks in different urban and rural parts of the district and their clinics have been sealed.

But no action has been taken on unscreened blood transfusion which is reported to be a common local practice. Most private blood banks and clinics do not bother to check if the blood being given to a patient is tested for the presence or absence of HIV and AIDS.

Another related problem seems to be the recycling of used syringes in particular and hospital waste in general. Heaps of medical-related garbage can be seen outside all government and private hospitals in Larkana. Several social workers and doctors in the district say some of this waste, especially syringes, is sold back in the market after it is washed and repackaged.

The writer is a staffer a the Herald.

This article was published in the Herald's June 2019 issue. To read more subscribe to the Herald in print.

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