In February, a handful of parents in southern Pakistan’s Larkana district brought their children to physician Imran Arbani’s clinic with similar symptoms, including pneumonia and uncontrollable fever. Arbani eventually asked a father to have his 16-month-old daughter tested for HIV.
“He got angry with me,” Arbani recalled. “He knew HIV was often spread through unsafe sex. He was an educated person but it took me a good two or three hours to convince him” to get his daughter checked.
The test came back positive. Six weeks later, Arbani had confirmed 20 HIV cases among children. Now more than 750 new infections have been reported in Larkana, including 615 children, an outbreak that World Health Organization officials describe as unprecedented among young people.
Pakistani officials believe the virus was transmitted through the use of dirty needles at health clinics, a common problem in one of the least developed corners of Pakistan. Sixteen children and two women have died because of infections, according to local doctors. Health teams backed by the WHO have swept in to conduct thousands of emergency screenings.
Pakistan’s health system is one of the world’s poorest, gripped by chronic shortages of qualified medical professionals and equipment, as well as social taboos that stand in the way of efforts to vaccinate children against basic diseases like polio – which remains endemic here and in only two other countries, Afghanistan and Nigeria.
Before the outbreak, scarcely more than 1,000 children were living with HIV in all of Pakistan, according to the WHO. The virus, which can lead to AIDS, attacks the immune system and leaves the body unable to stave off infections.
“The results so far are shocking,” said Sikandar Memon, head of the AIDS control program in Sindh province, which includes Larkana. “Unfortunately, lax medical practices in the area are common.”
Authorities arrested a local government doctor, Muzaffar Ghangro, one of the only pediatricians in the town of Ratodero, who reportedly treated many of the children for illness before they tested positive for the virus. While in custody, Ghangro also was found to be carrying HIV, but police said they found no evidence that he had injected patients deliberately.
He remains in custody, charged with negligence after authorities interviewed parents of 125 of his patients who said he had reused syringes that had not been properly sanitized.
Through his lawyer, Azhar Solangi, Ghangro denied the charges, saying that many of those who had contracted the virus had not been his patients. Solangi said Ghangro was being “made a scapegoat” for the HIV problem in Larkana, where a previous outbreak in 2016 was linked to the area’s transgender sex workers.
Arbani, credited with identifying the outbreak, said he has treated 100 HIV cases since February, the vast majority of them children. In a phone interview, Arbani said that in most cases the mothers were not carrying the virus and the children had not undergone blood transfusions – two of the main ways the virus is transmitted apart from sexual activity.
The epicenter of the outbreak is Ratodero and its surrounding villages, where many children suffer from diarrhea and other illnesses spread through poor hygiene and a lack of clean drinking water, and illiterate families sometimes seek medical treatment from unscrupulous practitioners.
“I can’t understand what happened to my son,” said Nisar Ahmad, the father of 18-month-old Saifullah, who tested positive for HIV in April after visiting Ghangro’s clinic.
Speaking by phone from the village of Allah Dino Seelro, Ahmad, a laborer, said his son and many other young children went to Ghangro’s office routinely to seek treatment for diarrhea. In a village of fewer than 1,500 people, 21 people were found to have the virus – including 17 children.
“Everybody knows everybody and it is not easy living with this disease here,” Ahmad said. “People have stopped visiting our home fearing their kids may also have caught this disease.”
Parents are now struggling with not only the stigma but also the burden of caring for infected children. Medication was being provided free of charge, but only in the Larkana district center, forcing some families to travel from the villages. To get medications for Saifullah, Ahmad, a father of nine, spent a day waiting in lines at a government hospital that was struggling to handle the influx of sick children and distraught parents.
In the last two months, 26,000 people in Larkana have undergone HIV screenings, according to health officials, who are also grappling with power outages and temperatures that have touched 120 degrees.
But in a district with some 300,000 residents, officials worry that many more infections have yet to be discovered – and not everyone is willing to be tested.
Last month, police arrested a villager near Ratodero for killing his wife after she was infected with HIV, accusing her of having sex outside the marriage. In another village, Arbani and other doctors found an HIV-positive woman who had been chained to a tree and had to persuade residents to set her free.
“There is a desperate need to raise awareness of HIV so that people don’t have taboos around it and don’t hesitate in seeking treatment,” said Maryam Yunus, a spokeswoman for the WHO in Pakistan. “This is one of the challenges we are trying to overcome.”
Memon said that by law, health officials could not force people to undergo HIV screening. Police have also tried to tackle the problem by arresting unlicensed caregivers, including the owners of unauthorized blood centers.
“Ghangro was the only qualified pediatrician in the area, but we cannot blame him alone,” Memon said. “The problem is bigger and we have been trying to find answers.”