In Pakistan the HIV epidemic is driven by injecting drug use. Our project in Pakistan aims to improve the human rights of people who use drugs by changing social attitudes and government policies, and improving the services and employment opportunities they can access. This will reduce the HIV risks they face, reduce HIV prevalence, and improve their overall health.

As part of the Bridging the Gaps programme, our in-country partner Nai Zindagi, supported by Mainline, has launched a pilot site which introduced a few innovative approaches in terms of service provision for people who use drugs. These approaches will be further implemented as part of the 2nd phase of a Global Fund HIV Grant for which Nai Zindagi is a principal recipient. This is a good example of how lessons learned within Bridging the Gaps can be embedded in other projects to ensure sustainability of achievements. Below an overview of these innovative approaches.

Innovative approach 1: CD4-diagnostics at ‘points of care’

Nai Zindagi has introduced a portable CD4 count machine to efficiently screen PLHIV who need Antiretroviral Therapy (ART). It is the first time that this technology is being used in Pakistan, and it is very needed since the numbers of places where a CD4 test can be done are very limited. The stress, costs, logistics involved with travel for people living with HIV and particularly PUD often result in very low access to this test. As a result, a majority of the people who need ART is unable to initiate treatment. The introduction of the mobile CD4 count machine will  effectively increase the number of PLHIV accessing the treatment they need. The portable CD4 machine also reduces the burden of CD4 count testing in hospitals. From all people living which HIV, only 18-20% have a low CD4 count which actually requires them to come to the hospital for a regular CD4 test. The portable CD4 count machine can filter out the other 80% who do not need to get a hospital test. This saves a lot of time, costs and energy. The portable CD4 analyser will also drastically increase the CD4 follow-up tests of beneficiaries.

Lower costs, equally reliable test results, more people accessing ART

Some special clinics providing ART have initiated treatment based on results of the Nai Zindagi CD4 analyser. In the very near future this CD4 point of care technology will rapidly expand across the country. The cost of these tests are lower than the static machines based on old technology and the results are equally reliable. In Phase II of the Global Fund grant three portable machines have been budgeted and approved based on project target and geographical spread. This intervention will cost-effectively increase the number of people living with HIV who can access ART.  The aim is that over the next 2 years, 5881 people (which is 90% of the PLHIV identified through voluntary testing and counselling services) will receive an initial CD4 count tests of which 50% will be followed up with CD4 testing as and when required.

Innovative approach 2: Treatment services for improving adherence to ART

In Phase II of the Global Fund grant, HIV positive people who use drugs with a CD4 below 500 will receive first preference to drug treatment services, after registering with the special AIDS clinics for initiation of ART. According to WHO guidelines, active drug users living with HIV should have access to ART. However, medical staff at public clinics in Pakistan attribute low adherence rates to active drug use and impose the condition of a ‘drug free status’. Therefore, people who use drugs  and communities receiving harm reduction services have strongly advocated and requested for drug treatment services. The Global Fund has agreed to support this intervention. A provincial coordinator and a social mobilizer will ensure smooth and uninterrupted access to ART in close collaboration with the Provincial AIDS Programs. An estimated 1,175 eligible PLHIV including PUD, spouses of HIV positive PUD, their children and other intimate partners are likely to receive ART.

Nai Zindagi has become the main driving force over the past couple of years in support and care for People Who Inject Drugs in Pakistan. Vision, dedication and the quality of its management make Nai Zindagi a highly regarded Principal Recipient of the Global Fund. The rise of HIV prevalence in the community of people who inject drugs is beyond alarming, and much more needs to be done in terms of coverage and provision of comprehensive harm reduction services. The Global Fund is proud to support Nai Zindagi in its efforts to make human rights-based care and prevention accessible to all people who inject drugs who need it. Dr. Werner Bühler, Senior Fund Portfolio Manager High Impact Asia Department Grant Management Division

Innovative approach 3: Adding a “+”to the Continuum of Prevention and Care for people who use drugs

The HIV and AIDS diagnostics, treatment, care and support unit developed by our partner Nai Zindagi under the Bridging the Gaps programme offers an ideal mix of a public-private partnership and lessons learned from the Continuum of Prevention and Care concept of the first phase of the Global Fund Grant. In phase II of the Global Fund Grant a “+” component will be added to the Continuum of Prevention and Care concept. This means that an estimated 1175 people who use drugs who are living with HIV will now have supervised access to ART and will receive regular follow-up. In addition, it is expected that more than 3000 spouses of people who use drugs will receive prevention packages that include condom provision and voluntary testing and counselling services.

Addressing the issue of multiple service providers at different locations

In Phase I of the Global Fund Grant people who use drugs who are HIV positive were referred to the community and home based care sites. However, this did not work and not more than 3-5% of referred clients could access services from these sites. The main reason was that the Continuum of Prevention and Care site and the community and home-based sites were not in the same location and the clients were reluctant to access yet another service provider. Moreover, the community and home-based sites were less geared to dealing with people who use drugs. Phase II of the Global Fund Grant offers a solution to this problem. Bridging the Gaps partners Mainline and Nai Zindagi are now discussing new areas for the programme in Pakistan, like human rights and drug policy reform oriented projects.