ISLAMABAD – Pakistan was once considered a low-prevalence country for HIV, but a series of outbreaks has infected hundreds of children and exposed fundamental weaknesses in its healthcare system.

Southern Pakistan has been particularly affected, with HIV outbreaks linked to healthcare facilities documented at Taunsa in Punjab, Karachi’s Kulsim Bai Valika (KBV) Hospital, and previously in Larkana and other districts. 

Some 331 children are estimated to have been infected with HIV at Tehsil Headquarters (THQ) Hospital in Taunsa since last October, and investigators have blamed their infections on preventable lapses in infection prevention and control (IPC).

Unlike outbreaks in many countries, where HIV transmission is primarily driven through sexual contact, repeated investigations in Pakistan have instead pointed to unsafe medical injections, poorly regulated blood transfusions and failures in sterilisation practices.

Despite the alarm being raised about the rise in children’s infections earlier in the year, an undercover expose by the BBC in April showed that health workers continued to use the same needles and syringes on several children at the facility.

Rise in new infections

Officials from the Common Management Unit, the government department dealing with HIV/AIDS, malaria and tuberculosis, reported to Parliament’s Standing Committee on Health last month that approximately 14,000 new HIV infections were detected during 2025, a figure far higher than previous annual reports.

Although the country’s health ministry attributes much of the increase to expanded screening, which rose from around 37,000 people tested in 2020 to more than 374,000 in 2025, the rise has intensified concerns over persistent transmission in healthcare settings and among vulnerable populations.

For many health experts, HIV has become a barometer of Pakistan’s broader health system, revealing broader weaknesses in regulation, governance, surveillance and primary healthcare that extend well beyond the virus itself.

“Every outbreak should have been a lesson,” says Professor Hasan Abbas Zaheer, a World Health Organization (WHO) adviser on blood safety. “Similar failures continue to emerge in different provinces, indicating that the underlying problems have not been resolved.”

Zaheer believes that Pakistan is facing a broader collapse of infection prevention and control. Unless hospitals, laboratories and blood banks consistently adhere to internationally accepted standards – and regulators enforce those standards – the country is likely to continue responding to outbreaks after they occur rather than preventing them, he argues.

Taunsa and Karachi outbreaks

The Taunsa outbreak illustrates the consequences of these failures. Between late 2024 and early 2025, more than 330 children were infected, with three-quarters of infections occurring in children younger than five years.

Investigators found little evidence that their mothers were living with HIV, making mother-to-child transmission unlikely. Instead, the investigation pointed towards healthcare-associated transmission through unsafe injections, blood transfusions and inadequate infection control.

Instead, the investigation documented multiple breaches of basic clinical practice. Standard infection prevention protocols were often absent or ignored, while intravenous infusion sets were reportedly reused, waste disposal systems were inadequate and appropriate paediatric auto-disable syringes were unavailable.

Larger syringes that were designed for hospital procedures were sometimes used repeatedly in paediatric care, increasing the risk of cross-contamination.

Meanwhile, a government investigation into an HIV outbreak involving 130 people – mostly children – at Karachi’s government-run Kulsum Bai Valika Hospital reported back last month. 

It blamed the increase in HIV cases documented from last October on failures in sterilisation procedures, improper handling of single-use syringes, inadequate supervision, poor biomedical waste management and weak compliance with infection prevention guidelines.

Provincial authorities have since suspended dozens of healthcare workers and administrators while strengthening treatment services for affected children.

Ban on substandard syringes

Last month, following a high-level review of the HIV outbreaks ordered by Prime Minister Shehbaz Sharif, officials recommended several reforms aimed at strengthening infection control, improving surveillance and tightening regulation of medical devices. 

These include a nationwide ban on the manufacture and use of substandard syringes. The Drug Regulatory Authority of Pakistan (DRAP) has also approved the phase-out of conventional disposable 1cc and 10cc syringes from January 2027, extending earlier regulations that already required auto-disable syringes for smaller volumes.

The decision follows years of evidence linking syringe reuse to HIV outbreaks. Investigations into recent clusters consistently identified unsafe injections as one of the principal drivers of transmission.

In many facilities, particularly where infection prevention standards are weak, single-use syringes and intravenous equipment have reportedly been reused or handled improperly, allowing blood-borne viruses to spread between patients.

Systemic problems

Experts caution, however, that focusing solely on syringes risks overlooking broader systemic issues. 

Unsafe injections are often a symptom rather than the root cause of the problem. Weak regulation of private clinics, inadequate inspection systems, inconsistent enforcement of infection control standards and shortages of trained healthcare workers all contribute to an environment in which unsafe practices can persist.

Former federal health minister and WHO official Dr Zafar Mirza argues that the recurring outbreaks should be viewed as evidence of wider governance failures. 

The Taunsa outbreak, he said, exposed shortcomings not only in infection prevention but also in blood safety, healthcare regulation, disease surveillance and accountability.

Although a government task force has proposed reforms across these areas, implementation has remained slow even as new clusters continue to emerge.

Inadequate surveillance 

While unsafe medical practices have attracted the greatest public attention, Pakistan’s surveillance system represents another major vulnerability.

The Ministry of Health estimates that more than 84,000 people are currently registered as living with HIV and receiving care through the national programme. However, officials acknowledge that the true burden is substantially higher – and the WHO and  UNAIDS put the figure at over 350,000 people.

Federal Health Minister Mustafa Kamal recently said that approximately 20,000 additional infections remain unreported, despite a dramatic expansion of HIV testing capacity over the past five years.

Health authorities argue that the sharp increase in reported infections partly reflects improved case finding rather than an explosion of transmission. Screening capacity has expanded tenfold since 2020, enabling health workers to identify infections that previously remained undiagnosed.

But weak surveillance continues to limit Pakistan’s ability to detect emerging hotspots before they become full-scale outbreaks. 

The Taunsa investigation also found that hospitals and clinics lacked reliable digital reporting systems, standard case notification procedures and mechanisms for sharing surveillance data between districts and provinces. These gaps delayed recognition of transmission patterns and slowed public health responses.

Tracking patients after diagnosis also remains a major challenge. Parliamentary discussions highlighted the problem of “missing patients”: individuals who register at antiretroviral therapy (ART) centres but subsequently discontinue treatment or are lost to follow-up.

Without effective counselling and monitoring, these interruptions increase the risk of poorer health outcomes and continued HIV transmission.

Public health specialists argue that surveillance should extend beyond simply counting new diagnoses. It should also identify transmission networks, monitor healthcare-associated infections, evaluate infection prevention practices and rapidly detect clusters before they spread.

Zaheer believes Pakistan could strengthen these efforts by integrating surveillance data across provinces and using digital technologies, including artificial intelligence, to identify emerging hotspots in real time.

Stigma limits HIV response 

While Pakistan has expanded HIV testing and treatment services in recent years, prevention has not kept pace with the changing nature of the epidemic. 

The number of government-supported antiretroviral therapy (ART) centres has more than doubled from 44 in 2020 to 97 in 2025, with plans to increase the network to around 166 facilities. But access remains uneven, particularly outside major cities.

For many Pakistanis, HIV testing is still not part of routine primary healthcare. Instead, people are often tested only after they develop symptoms, require surgery, donate blood or are identified during an outbreak investigation.

Stigma remains one of the greatest barriers. Health officials told the Parliamentary health committee that fear of discrimination discourages many people from seeking testing or treatment, while misconceptions about HIV continue to fuel secrecy and delayed diagnosis.

The Pakistan Medical Association (PMA) has also warned that thousands of infections remain undetected because people are reluctant to access healthcare services for fear of being ostracised by their families or communities.

Pakistan’s HIV epidemic remains concentrated among people who inject drugs, men who have sex with men, transgender people and sex workers. These groups frequently encounter discrimination in healthcare settings and are often excluded from mainstream health programmes. 

Community organisations have long argued that HIV services remain overly dependent on donor-funded outreach projects rather than being integrated into routine primary healthcare.

Hidden sexual networks?

Although the outbreak primarily affected children infected through unsafe healthcare practices, investigators also warned of “hidden sexual networks” operating largely outside existing surveillance and prevention programmes.

Without confidential testing, community outreach and culturally appropriate prevention services, these networks could sustain HIV transmission while remaining largely invisible to health authorities.

Women also face distinct barriers. Although Pakistan has made progress in preventing mother-to-child transmission, reproductive health services and HIV care are often delivered separately, limiting opportunities for routine screening and counselling during pregnancy.

Many women are diagnosed only after a spouse or child tests positive, reflecting broader gaps in sexual and reproductive healthcare.

The PMA has urged the government to make confidential, rapid HIV testing available free of charge across primary and secondary healthcare facilities, while investing in training for healthcare workers to reduce discrimination and improve counselling. It has also called for greater access to modern biomedical prevention strategies alongside expanded treatment services.

Although antiretroviral medicines suppress the virus and dramatically reduce the risk of transmission, they depend on early diagnosis, uninterrupted drug supplies and sustained patient engagement.

Without addressing stigma, expanding community-based prevention and ensuring equitable access to care, many people will continue to enter the health system only after they become seriously ill—or after an outbreak has already occurred. 

Could long-acting HIV prevention change the response?

While Pakistan struggles to contain healthcare-associated outbreaks, the global HIV response is entering a new era defined by long-acting prevention technologies that could dramatically reduce new infections.

Lenacapavir, a long-acting injectable medicine administered only twice a year, has demonstrated almost total prevention of HIV transmission in clinical trials.

Researchers also reported progress on other long-acting technologies, including injectable combinations that provide both contraception and HIV prevention, three-month vaginal rings and real-world implementation of a monthly injectable cabotegravir in African countries.

Global health experts increasingly view these medicines as potential game changers, particularly for people who struggle to take daily oral pre-exposure prophylaxis (PrEP). Receiving two injections a year could substantially improve adherence while reducing the risk of HIV transmission among people at elevated risk of infection.

But Pakistan has yet to establish broad access to conventional HIV prevention services. Oral PrEP remains available only through limited pilot initiatives and donor-supported programmes.

Long-acting injectable prevention is therefore unlikely to become widely accessible without significant investment, regulatory approval and financial support from international partners.

Experts nevertheless argue that Pakistan should begin preparing now rather than waiting for the medicines to become widely available globally. Planning for procurement, regulatory approval, healthcare worker training and financing could enable the country to introduce new prevention technologies more rapidly once prices fall and generic versions become available.

Mirza believes Pakistan’s response must move beyond emergency outbreak management towards a comprehensive public health strategy that integrates infection prevention, disease surveillance, blood safety, governance and community engagement.

Zaheer also sees an opportunity to modernise Pakistan’s surveillance systems through digital technologies. Better integration of laboratory data, hospital reporting and provincial surveillance could help identify emerging clusters before they expand into large outbreaks. Artificial intelligence, he argues, could assist health authorities in recognising transmission patterns, predicting hotspots and directing scarce resources towards areas of greatest need.

Yet specialists caution that new policies and regulations alone will not prevent future outbreaks if enforcement remains weak. Previous bans on conventional syringes were inconsistently implemented, allowing unsafe products to remain widely available. Likewise, investigations following successive HIV outbreaks have repeatedly identified similar failures in infection prevention despite earlier recommendations.

Image Credits: BBC, Wuestenigel/Flickr, Hamid Inam/ WHO Pakistan.