Hundreds of babies and toddlers have been found infected with HIV in a Pakistani city, in what may be an unprecedented outbreak of the virus where children are the worst affected.
Three-quarters of those testing positive for the virus since the outbreak was discovered a month ago in Rotadero in Sindh province are children, with nearly two-thirds aged five or under.
Unqualified 'quack' doctors sharing dirty needles for injections, intravenous drips and blood transfusions have been blamed for spreading the virus, which attacks the immune system and leads to AIDS.
Dr Maria Elena Filio-Borromeo, Pakistan director for the United Nations' AIDS and HIV programme, said she had not seen anything similar in Asia.
“This one is just unprecedented. It's such a very unique kind of profile, because those infected are children.”
The children have been infected in a country where HIV treatment remains rare for the poor, and where 6,200 people died from AIDS in 2018.
The outbreak was detected when a paediatrician in the area was concerned eight of her young patients were finding it difficult to shake off fevers and not getting better when given medicine. Testing found all eight were HIV positive and a screening programme was started in the city a month ago. Since then 18,418 people have been screened and 607 have been found positive. Of those, 381 are aged five or under. The figure is expected to rise as screening increases.
According to United Nations estimates, 150,000 people in Pakistan have HIV and the number is increasing by 20,000 a year. But only one-in-50 women and one-in-25 men have ever been tested.
Police in Sindh earlier this months said they had shut down a string of quack clinics and said they had arrested a doctor they accused of spreading the virus. The doctor has denied wrongdoing.
The region has been hit by an outbreak before. In 2016 more than 1,500 people were found to be infected, with most of them men linked to the area's sex workers. Lax hygiene by quacks may have allowed the virus to spread from this high-risk group to the wider community, doctors believe.
Dr Filio-Borromeo said Pakistan had good regulations for making the virus did not spread, but those regulations were rarely enforced.
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Researchers have yet to determine the exact source of the outbreak, but believe the virus has been spread by 'quack' doctors who specialise in injections and drips, but do not use clean needles.
Many local patients have a culture of demanding injections and drips when they are sick, believing they are quicker and more effective than other medicines, Dr Filio-Borromeo said.
Unqualified quack doctors running backstreet clinics to fill gaps in Pakistan's overstretched and underfunded public health system, are happy to oblige.
“Patients say: 'If you will not give me a drip, I will go to another doctor,'” she said.
“Education is so critical. You can provide all this mass testing, all the treatment, but educate people.
First on the reduction in the demand of unnecessary injections.”