Every time Pakistani cities are listed in order of prevalence of Human Immunodeficiency Virus (HIV), Karachi tops the list as the top contender, and the reports juxtapose it with the fact that Karachi has only one treatment centre each for the disease in the public and private sectors, and a third one has just started operations in the private sector.

These are clearly not enough for a city with an estimated population of 24 million. While the listings are apt, the reasons for this high prevalence are often lost. "Karachi is the most populous city of Pakistan. It has the largest number of migrants moving here due to urbanisation and other factors," says Dr Sikandar Iqbal, Focal Person, HIV Treatment and Care Services, Sindh AIDS Control Programme (SACP).

"The city has the largest number of inmates in prison in any part of Pakistan -- close to 14,000. It has the largest number of female sex workers anywhere in Pakistan -- an estimated 27000. The law and order situation here leads to a lot of unrest. All these factors lead to more drug addictions. As a result, we have groups of people most vulnerable to contracting HIV in Karachi -- migrants, inmates, sex workers, IV drug users," he adds.

According to Dr Younis Chachar, Programme Manager, SACP, it is important to understand the difference between numbers of HIV positive cases as opposed to those with full blown Acquired Immune Deficiency Syndrome (AIDS).

The number of reported cases in Sindh since 1995 is 11985, says Dr Chachar. "Out of these, 11746 were HIV positive and 239 were full blown AIDS. Sindh has not had any reported cases since the last two years. We have had 8341 HIV positive cases in Karachi, and 78 cases of AIDS."

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When people say Karachi has the highest number of HIV patients in Pakistan, they often fail to see the dynamics, says Dr Iqbal. "Do we know how many of the advanced stage HIV patients from rural Sindh, and all other provinces, land up in Karachi for treatment? When HIV patients in Karachi are counted, it is not taken into account where they have come from. All that is noted is that they were diagnosed in Karachi."

Treatment centres are divided into those for adults and for children, with a sub-division for pregnant mothers. For adults, SACP has two centres in the public sector -- one in Civil Hospital Larkana and another in Civil Hospital Karachi. In the private sector, the centre at Indus Hospital Karachi is supported by SACP, and a new one in the private sector has begun operations at Aga Khan University Hospital.

Dr Samreen Sarfaraz, Consultant, Infectious Diseases at the Indus Hospital, Karachi, says the vulnerable group that poses the biggest challenge is IV drug users. "They transmit the virus in many ways; needle sharing with infected blood, drug users resorting to prostitution, selling their blood, their families getting them married in the hope that they will give up drugs," she says.

AIDS patients get severe skin infections and boils, and for the treatment many of them go to small clinics and quacks who do not sterilise surgical equipment; through this channel, the disease spreads further. "It is very tough to treat drug users because they lie a lot. IV drug users are the drivers of infection and they do not come to us themselves for treatment. Often, our staff picks them up from the hotspots," says Dr Sarfaraz who has been working with HIV positive patients for four years.

However, the focus on IV drug users as the key population in the spread of HIV may result in neglecting other vulnerable populations. Ali Asghar, Program Director, Parwaz Male Health Society, feels much needs to be done to raise awareness among MSM and sexual minorities. "There is a huge unmet need for contraceptives that can help control the spread of AIDS. Our outreach workers distribute condoms free of cost. We try and raise awareness so that people do not indulge in risky sexual behaviour and are cautious against Sexually Transmitted Infections (STIs)," he says. Dr Sarfaraz says that the number of patients is definitely on the rise but is not being reported. "Initially, HIV was only prevalent among people who had travelled abroad or were expatriates returning to Pakistan. Our patients include people from all strata. Patients of this illness are a very resistant population."

However, Dr Iqbal believes that it is not just that the number of patients has increased; the awareness has also increased, which means more patients are getting tested and treated, and, thus, we see the numbers increasing. "The patients were always there. Now we know that they are there," he says.

While much is being done to mitigate the spread of the disease, it is not enough, according to Dr Sunil Dodani of SIUT. Dr Dodani handles AIDS patients that are serious, and are referred to SIUT from the treatment centre of SACP at Civil Hospital. "More needs to be done to control the spread of AIDS. We need to raise awareness and educate people about how it is spread, as well as pick up patients more efficiently."

The stigmatisation of vulnerable communities poses a challenge as due to social attitudes patients do not come out and get themselves tested or treated.

The stigmatisation and what Asghar calls "criminalization" of vulnerable communities, poses a challenge, as due to social attitudes, patients do not come out and get themselves tested or treated. In the opinion of Dr Chachar, the biggest challenge is changing behaviours towards this illness. "Social acceptance is important. It will be a step forth when people start eating with HIV positive people. Everyone must realise that being HIV positive does not necessarily mean the person was promiscuous."

"One could contract it during a tooth removal or getting a tattoo. We have six-year-olds who got HIV due to ear piercing. Women whose husbands have tested HIV negative have gotten it via blood transfusion or unsterilised surgical equipment during child birth. The character judgment has to stop. It is now a curable disease. We have to treat it like any other illness," he adds.