HIV Outbreak and Sanitation Concerns in Pakistan

In late April of 2019, Pakistan uncovered their latest HIV outbreak. The outbreak was discovered in the Ratodero neighborhood located in the city of Larkana. In the Sindh province in southern Pakistan, investigative, diagnostic, and recovery efforts continue. While this is not the first HIV outbreak Pakistan has experienced, it is the most recent. This outbreak is unique due to the child demographic impact and outbreak size. As more people are tested, and the number of infected individuals continues to increase, following up with investigative efforts, response, and recovery is important. Areas experiencing and recovering from global hazards, such as outbreak, are particularly vulnerable to exploitation by terrorist organizations. This latest outbreak contributes to Pakistan’s vulnerability amid misinformation, miseducation, and escalating concerns of insufficient health care, health care system failure, and overall distrust of the health care system.

Initially, the outbreak was uncovered and associated with a pediatrician office in Ratodero. The clinic was run by Dr. Muzaffar Ghangharo. Multiple children were experiencing fevers that would not subside over extended periods of time. The fevers were unresponsive to treatment. Some parents decided to take their children for a second opinion at a clinic in the city of Larkana. At the clinic in Larkana, run by Dr. Imran Arbani, children were tested for HIV as a precaution, since prolonged fevers are a symptom of the virus. When the tests returned positive, the results were perplexing given the HIV negative status of many of the mothers. The age range of the infected children was 2 months to 8 years old. While the initial outbreak was focused on the clinic of Dr. Ghangharo, the ongoing investigation has linked major health care system failures and sanitation concerns to the current outbreak. Numbers released on July 2, 2019 show 735 children and 159 adults have been newly diagnosed with HIV in Larkana since April 2019.

Investigative, response, and recovery efforts continue on behalf of the government in Pakistan and global health organizations. World Health Organization screenings identified several risk factors, including: “unsafe intravenous injections during medical procedures; unsafe child delivery practices; unsafe practices at blood banks; poorly implemented infection control programs; and improper collection, storage, segregation and disposal of hospital waste”. In addition to negligence in local health care systems, officials have identified a large number of unqualified individuals practicing medicine in the region. As a result, 61 clinics deemed unsafe have been “sealed” and 29 other clinics have been warned in reference to their practices.

As investigative efforts look into why and how this outbreak happened, the main culprit seems to be poor medical practices. The main contributing practices are needle repackaging and reuse. Additional medical scenarios include poor blood transfusion and dialysis practices, which can involve repackaged or reused needles and medical supplies. A third avenue of viral transport is centered around razorblade reuse and unsanitary practices at barbershops. At this time, the World Health Organization has declared this outbreak a Grade 2 emergency, which requires moderate response. The Pakistani government has approved $6.3 million to address all aspects of the outbreak. So far, this fund has been used to support public testing efforts, as well as treatment, counseling, and community education efforts.

The demographic of the outbreak is particularly concerning for many reasons, including response and recovery efforts. Mass numbers of new HIV cases in such a young population is atypical. Additionally, drug treatment for HIV is age specific. Thus, HIV treatment for the particular demographic of this outbreak is not found in abundance.

Pakistan has endured five HIV outbreaks since 2003. Each outbreak has been associated with varying issues that may also be linked in certain ways. In 2003, an HIV outbreak occurred among intravenous drug users. A second outbreak in 2016, infected 12 pediatric patients in a hospital. Also in 2016, an outbreak linked to sex workers prompted mass testing which identified 1,521 new HIV cases. Later in 2016, another outbreak infected 206 patients in a dialysis unit. Along with the latest 2019 outbreak, the outbreak in 2003 associated with injectable drug use and the 2016 outbreak linked to a dialysis unit occurred in the city of Larkana, which has very few antiretroviral therapy clinics.

Meanwhile, Pakistan continues to struggle with sanitation issues. Heavy rains have backed up and overflowed sewer systems. These systems are not typically sound, commonly flowing into local waterways. Amid reports of waste piling up on the outskirts of cities, additional reports on social media broadcast medical waste, including used syringes and vials of blood washing up on one of Pakistan’s most popular beaches in Karachi.

Concerning HIV and other diseases, Pakistan is fighting battles against misinformation and health care system distrust. For example, Pakistan has been fighting immunization misconceptions for decades. One misconception is that the polio immunization causes paralysis and infertility. Progress was being made throughout communities and polio cases were decreasing. However, earlier this year, when rumors began to spread that the polio vaccination was causing children to become ill, “six vaccinators or their guards were shot dead, forcing officials to temporarily suspend their immunization efforts. And at least 15 new cases of polio have been reported this year.”

The latest HIV outbreak along with misinformation and health care distrust has had major impacts on daily life in Larkana. Even though HIV cannot be transmitted through casual contact, some people have taken to avoiding social situations out of panic. Furthermore, “parents in the area fear their children's futures have been irreparably harmed after contracting HIV, especially in a country whose masses of rural poor have little understanding of the disease or access to treatment.” Many are refusing to get injections they deem unnecessary (including immunizations). Other impacts include people transitioning to electric razors to shave or get/give haircuts in order to avoid barbershop razor exposure.

The spread of HIV in Pakistan is linked to terrorism vulnerability. Pakistan is intimately involved in harboring terrorist organizations and fostering terrorist group growth and activity. Terrorist groups can take advantage of public instability created by the outbreak through participating in spreading additional misinformation that may benefit the organization or offering to provide resources or nefarious opportunities. This is a strategy that is not financially intensive or time intensive, given the current sensitive situation surrounding the HIV outbreak.

While there are many examples of terrorist organizations benefiting on behalf of government instability and lack of ability to provide for citizen basic needs, a large scale example of this exists with the history of the Taliban, al-Qaeda, and poppy growth in Afghanistan. In trying to cease Afghan government dependency on illegal drug trade and terrorist group activity, healthy avenues for citizens to provide for their families was not set up quickly enough on behalf of the newly established non-Taliban government. In this situation, it became a labor intensive and dangerous struggle for citizens to provide for their families using means being established by the new government that was still trying to gain footing. Consequently, the Taliban and terrorist groups were able to provide an avenue for citizens to take care of their families through offering food, money, supplies, or other resources a family needs, in exchange for growing poppy. The Taliban and terrorist groups would then exchange the desired survival resources for the poppy which was then cycled into international drug trade avenues for financial gain. This financial gain facilitated the continuation of terrorist activity and furthering terrorist organization goals.

Citizens of Pakistan will do everything in their power to ensure their basic needs and the basic needs of their children are met. If the government cannot support the need for proper healthcare, the people will look for other avenues to obtain what they need. Consequently, if terrorist organizations can support these types of needs or obtain and provide resources, then working with these organizations becomes a viable option for vulnerable citizens.

With citizens looking for scarce child-friendly antiretroviral drugs, another opportunity exists for terrorist organizations. The growing distrust of government healthcare and the inability of the country to provide basic healthcare needs and sanitary conditions leaves the population open to exploitation on behalf of terrorist organizations. Many terrorist groups are already involved in the trading of illicit or black market drugs. This activity provides an untraceable financial avenue the help these organizations maintain funding. Parents that are desperate for antiretroviral drug treatment for their children may be susceptible to recruitment if a terrorist group claims to provide needed drug treatments. Whether the drugs provided are legitimate or not is another issue. For example, a terrorist organization my recruit a Palistani citizen by asking the citizen to complete tasks or gather information in exchange for life-saving HIV drugs that can be administered to the citizen’s ill child. In reality, the drugs may be real, black market variations, or fake and potentially harmful. Regardless, the terrorist organization will benefit from exploiting the citizens and vulnerability created by the lacking healthcare system. Struggles with misinformation, public distrust of healthcare, failing healthcare practices, and growing sanitation issues serves to make the population of Pakistan even more vulnerable to terrorist exploitation.

The Counterterrorism Group (CTG) works to detect, deter, and defeat terrorism around the world. Purposefully investigating, analyzing, and addressing developments and the subsequent global impacts surrounding health issues, such as disease outbreaks, will provide CTG with information needed to identify threats and areas of vulnerability and concern. Using this process, the CTG Emergency Management, Health, and Hazards (EMH2) Team can progress toward defeating terrorism by helping predict, prepare for, and lessen the negative impacts of global hazards. Lessening the impact of global hazards will decrease the availability of exploitable circumstances for terrorists and terrorist groups. The CTG EMH2 Team is currently tracking critical health issues and outbreaks of disease happening around the globe. The team is also collaborating with regional CTG teams to identify areas of concern and analyze potential impacts linked to these circumstances Please do not hesitate to contact us with any information or questions.

1. Medical Investigation: How Did 494 Children In 1 Pakistani City Get HIV?, NPR, May 21, 2019,

2. Whatever Happened To ... The 494 Children Who Got HIV In 1 Pakistani City?, NPR, August 30, 2019,

3. HIV cases–Pakistan, World Health Organization, July 3, 2019,

4. Nearly 500 Children Have Been Infected With HIV in a Single Pakistani City. Here's What to Know, TIME, May 23, 2019,

5. Emergencies, World Health Organization, 2019,

6. Whatever Happened To ... The 494 Children Who Got HIV In 1 Pakistani City?, NPR, August 30, 2019,

7. Pakistani children worst affected in HIV outbreak, BBC News, May 21, 2019,

8. HIV cases–Pakistan, World Health Organization, July 3, 2019,

9. Karachi's Clifton Beach swamped by syringes and medical waste, BBC News, September 3, 2019,

10. Hundreds of children in Pakistan have been infected with HIV. Used needles could be to blame, The Washington Post, June 6, 2019,

11. Over 537 children test HIV positive in Pakistan village, GULF NEWS, May 26, 2019,

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