Islamabad: The actual prevalence of HIV among key populations in Pakistan during the 6th Round of the Integrated Biological and Behavioral Surveillance (IBBS) was ‘significantly higher than reported’ in preliminary findings presented last week.
However, due to the exclusion of faint lines on rapid diagnostic tests-clear indicators of HIV-the official prevalence rates were artificially lowered, The News has learnt.
According to the data available to this scribe, 2,057 (32%) people who inject drugs (PWID), 1,295 (17%) men who have sex with men (MSM), 826 (12.3%) female sex workers (FSWs), and 2,542 (33%) transgender persons (TGs) showed faint reactive lines on their initial tests but were not subjected to further confirmatory testing. This omission has raised serious concerns about the accuracy of Pakistan’s HIV surveillance.
Guidelines issued by WHO, as well as the manufacturer’s instructions for Rapid Diagnostic Kits, clearly state that any faint lines-no matter how faint-must be considered reactive or HIV positive, necessitating a second confirmatory test.
Despite these clear protocols, IBBS implementers disregarded faint lines, excluding a large portion of potentially HIV-positive cases from official estimates, effectively downplaying the severity of the epidemic.
The 6th round of IBBS, conducted after nearly a decade by the Health Services Academy (HSA) in collaboration with the Progressive Development Initiative (PDI), UK, and the WHO Collaborating Center for HIV Surveillance (HIVHUB), Iran, surveyed 28,377 individuals. These included 6,500 PWID, 7,606 MSM, 6,670 FSWs, 7,601 TGs, and 5,000 prisoners.
Preliminary results presented to the Ministry of National Health Services, Regulations, and Coordination indicated a concerning rise in HIV prevalence among TGs (10% from 7.2% in 2016), MSM (7% from 5.6%), and FSWs (3.8% from 2.2%).
The prevalence among PWID, however, showed a decline from 38.4% in 2016 to 27%, largely attributed to harm reduction programs. However, newly surfaced data on faint-line results suggests that the actual prevalence could be even higher than reported.
Yet, the failure to retest individuals with faint lines casts serious doubt over these figures. According to national HIV program officials, the actual number of HIV-positive cases could be significantly higher than reported.
One example cited was an individual who initially tested with a very faint line but, upon retesting with Determine Early Detect using a different lot number, showed a strong reactive line, confirming HIV positivity.
Minutes from a review meeting held in June 2024 reveal that IBBS implementers were explicitly advised to consider faint lines as HIV-positive cases, following WHO and manufacturer guidelines.
The recommendations included considering all RDTs with faint red lines as reactive and ensuring confirmatory testing, an external consultant review, and AI-assisted analysis to validate the data, ensuring that the Global Fund (GF) was informed about the revised protocol and findings.
Despite these recommendations, IBBS implementers failed to act on this guidance, raising suspicions that the exclusion of faint-line cases was deliberate to artificially show a lower HIV prevalence among key populations.
This revelation has sparked outrage among health professionals and HIV advocates, who argue that such negligence compromises Pakistan’s ability to formulate effective public health interventions. Underreporting HIV cases risks misallocating resources, reducing funding for prevention programs, and misleading policymakers about the actual scale of the epidemic.
A senior official in the national HIV program who requested anonymity expressed concern over the mishandling of test results: “Ignoring faint lines on rapid diagnostic tests is a serious breach of protocol. This decision has significant implications for HIV surveillance, funding, and public health policy in Pakistan.”
