Almost two months ago, I wrote about population growth in Pakistan and its deleterious effects, and I emphasised different forms of birth control especially condoms and their advantages in matters besides preventing unwanted pregnancies (All is not well-September 17, 2017). Condoms are also almost the only method available in preventing most Sexually Transmitted Diseases (STDs).

Most people when they think of STDs think of Gonorrhoea or Syphilis. But one of the most alarming epidemics in Pakistan is of Hepatitis C (Hep C). Almost all possible causes of transmission of Hep C are discussed frequently in the media but the fact that Hep C is also transmitted through sexual intercourse is rarely ever mentioned.

During my practice in Pakistan I saw many young women come for heart surgery and were found to have Hep C. A careful history excluded common causes of becoming infected with Hep C like previous blood transfusions and past surgical or dental procedures but sadly it was and still probably is extremely difficult to drag in their spouses to test them for Hep C. Fortunately, if detected early Hep C is now much more treatable than in the past.

There still are many Hep C patients that will only be diagnosed once they develop symptoms of liver failure or liver cancer and by then treatment options are severely limited.

The one thing I worry about is the dissemination of the virus (HIV) that causes Auto Immune Deficiency Syndrome (AIDS). Once this virus enters the population groups as it apparently has started to do, it can also spread as quickly and widely as the Hep C virus. And of course the spread of both these diseases happens in the same way.

One of the reasons Hep C as well as HIV-AIDS are often not diagnosed early is because in both the initial infection is often of a mild nature and might be missed. And treatment of both these diseases when they have advanced is difficult and as is more relevant in a country like Pakistan, much more expensive. Obviously the best thing is to prevent these diseases from spreading in the first place. To make that happen, the ‘usual culprits’ need to be addressed but so must sexual transmission be addressed.

For the last year or so there has been movement in establishing some tests prior to marriage. The Punjab government seems to be particularly interested in testing couples for Thalassaemia, an inherited disease. A great idea but if blood tests are being done before marriage then why not for other important diseases especially those spread by close contact. And sexual contact being probably the closest of all contacts between two people.

Coming back to where I started, it is important to test people for STDs before marriages and the list of STDs should be enlarged to include HIV-AIDS and Hep C, as well diseases like Thalassaemia. Here a caveat. It is highly unlikely that premarital blood or other tests will ever become an established routine in Pakistan. The reasons for this are many -- ignorance, lack of education and superstition just being a few of these reasons.

And yes, we can make laws mandating these tests before a marriage can be registered with NADRA to get new ID cards for the spouse after marriage but also before children can be registered with NADRA. I can easily imagine an entirely new industry responsible for providing false pre-marital test results to fulfil NADRA requirements.

And all the marriages going on in villages and small towns will probably ignore any such regulations. I can even imagine ‘religious divines’ opposing such regulations in the first place. Marriage in Pakistan is still primarily a religious affair.

Of course forcing people to get blood tests before marriage or at any time seems like a violation of basic rights including the right to privacy. But in a country like Pakistan where public health issues are so often completely ignored, premarital blood testing might serve as an important method to limit the spread of communicable disease.

I have often written quite about the Hep C epidemic in Pakistan but more recently there seems to be an increase in the incidence of diagnosed HIV-AIDS patients. Hard numbers are difficult to come by and most estimates are really just that, estimates and as such can be quite different from what the actual numbers might be. Most importantly the stigma still attached to this disease will prevent many people that might be at risk to get tested.

One of the reasons I worry about HIV-AIDS is that I just went into medical practice in the United States at about the same time that this disease became common but did not have a name yet. At first it was called the ‘gay plague’ but soon its victims started to appear in the non-gay population also. The early eighties was a terrifying time for surgeons like me that had just started working in a place where this new disease seemed to be spreading rapidly.

Just imagine the idea that was actually pushed that surgeons should wear Kevlar (bullet proof material) gloves to prevent injury during routine surgery. After all a knife or needle prick during surgery on an infected patient could also infect members of the surgical team. An entirely new paradigm of surgical practice in the operating room was established to prevent transfer of this disease from the patient to those that were treating the patient.

In my specialty of cardiac surgery, blood transfusion is a frequent requirement. After the ability to test for HIV, the blood supply became safer. But during the period that this disease first appeared and when it could be tested for in blood available for transfusion, many patients undergoing cardiac surgery became infected with HIV. Therefore, decreased amount of blood transfusions or ‘no transfusion’ cardiac surgery became common. I tried to make it possible during my practice in Pakistan.

In a couple of years, we had a name for this disease and knew what caused it. Still, during much of the eighties, a diagnosis of HIV-AIDS was considered a death sentence. Things are better today but in a country like Pakistan there is neither the will nor the resources to tackle this disease if it does really start spreading among people like Hep C already has.

It is perhaps important to emphasise that transmission of Hep C as well as HIV-AIDS can only occur if infected fluids (especially blood) containing the living virus from an infected person comes in contact with or enters the blood stream of an uninfected person.

So, during my practice in the US, one of the major class of patients infected with HIV-AIDS were intravenous drug abusers that shared ‘infected’ needles. I am sure that the same group is highly at risk in Pakistan. And unique to Pakistan are the unscrupulous medical ‘practitioners’ that reuse needles in multiple patients without adequate sterilisation.

So the big question then is who should be tested preferentially. Sex workers, intravenous drug addicts, incarcerated persons, all blood donors, and all persons scheduled to undergo surgical procedures should, if possible, be tested for HIV. And that is just a beginning.