Identifying undiagnosed HIV infected individuals in a community-based door to door testing initiative in outbreak affected areas of Larkana and surrounding districts, Pakistan.

Background: In April 2019, an outbreak of HIV was reported in Larkana district of Sindh province, Pakistan. The outbreak primarily affected children and was associated with unsafe injections in healthcare settings. Testing services delivered from health care facilities continued to identify new HIV infections in Larkana and surrounding districts. We describe a community-based educate, test and treat initiative implemented in these areas to identify undiagnosed HIV infections in the community. We analyzed the data to describe HIV-positivity, linkage to care and HIV risk exposure among diagnosed persons. Methods: HIV rapid testing was offered door-to-door to people 18 months to 60 years of age who were not known to be HIV-positive. Testing was conducted in 12 union councils (UCs; lowest administrative unit) of Taluka/sub-district "Ratodero" (district Larkana), four UCs of Taluka "Garhi Yasin" (district Shikarpur) and seven UCs of Taluka "Garhi Khairo" (district Jacobabad). Those with two reactive rapid results in the community were referred for confirmation and linkage to care at the nearest HIV treatment centre. We calculated HIV positivity (number of people with two reactive rapid tests in the community among those tested) disaggregated by age, sex and location, and assessed the proportion linked to care among those HIV-positive and self-reported HIV risk exposure among those diagnosed. Findings: Between 6 and 21 September 2023, 43,883 individuals were tested in Ratodero, of whom 47% were females and 47% were aged <15 years. Of those tested, 73 (0.17%) were HIV-positive (48 persons aged <15 [0.24%] and 25 persons aged ≥15 [0.11%]) and 63 (86%) were linked to treatment. Forty eight persons (76%) reported exposure to reused needles or syringes. In surrounding areas, between 28 November to 12 December 2023, 24,352 individuals were tested, of whom 60% were females and 49% were aged <15 years. Of those tested, 158 (0.65%) were HIV-positive (56 persons aged <15 [0.47%] and 102 persons aged ≥15 [0.83%]) and 94 (59%) were linked to treatment. Forty seven persons (51%) reported reuse of needles or syringes and 15 (16%) transfusion of blood/blood products. Interpretation: More than five years since the nosocomial HIV outbreak in Ratodero, undiagnosed HIV infections persist in the community. The undiagnosed HIV infection is common among children in Ratodero, and among both adults and children in surrounding areas. Self-reported HIV risk exposures point to reuse of needles and syringes as the predominant mode of transmission. The situation warrants urgent need to address unsafe injection practices and safety in healthcare facilities. Funding: The educate, test and treat programme was funded through the Global Fund COVID-19 Response Mechanism country grant. No specific funding was received for this programme analysis and evaluation.