Doctors in Pakistan like to give injections to satisfy patients. Providers can also make extra money by adding an injection to the prescription, even when the ailment can be treated with pills or other medicine.
In poorer areas of the country, some providers reuse syringes in order to cut corners and save money.
That is why the unfolding scandal in Ratodero, a city in Pakistan's southeast Sindh province, where almost 1,000 people have been diagnosed with HIV thought to be caused by unsafe needles
-- as horrifying as it is -- shouldn't come as a great shock.
Media coverage has focused on that city and the particular providers involved, but the reusing of needles, often for unneeded injections, has contributed to a growing crisis on a national scale.
Pakistan has seen multiple outbreaks of hepatitis B, and has one of the highest burdens of hepatitis C infection in the world, largely due to the continued use of unsafe injections.
Hepatitis can lead to numerous complications, but it is not usually deadly, unlike HIV which in poorer communities can often develop into AIDS and prove fatal.
Pakistan's HIV rate has been steadily rising since 2000, in part because many prevention programs focused on syringe and needle exchanges, disease and condom awareness never got off the ground, or even when they did, were unable to attract sufficient support to make much of an impact.
Treatment for HIV is provided for free in Pakistan, but it can only be effective when those infected with the virus are aware of their status.
The steady spread of the virus through reusing needles, combined with a lack of prevention programs and awareness has resulted in the infection level reaching a dangerously high level among at risk populations.
Among intravenous drug users, the prevalence of HIV has been documented at 38%, while the rate among transgender sex workers, another at risk population, is above 10%.
Tackling the crisis
In Pakistan, a large proportion of primary health care is carried out by private providers.
There has been a mushrooming of the private sector in recent years because of myriad problems within the public health system, most prominent of which was the closure of the majority of government health centers around 2 p.m. each day. This meant working people had no choice but to visit private providers in the late afternoon or evenings.
Unfortunately, unsafe injection practices are common at private clinics and dispensaries. In areas where literacy rates are low, many times the patient may not even know if the provider is trained or licensed to practice medicine. There is hardly any concept of infection control, and the reuse of syringes and needles at blood-stained preparation counters is a common sight.
This has led to numerous outbreaks of both hepatitis B and C, and in more recent years, the spread of HIV among previously low-risk communities.
Larkana, another city in Sindh province, has seen three HIV outbreaks in the past 15 years. The first, in 2004, was among intravenous drug users. The second was linked to a dialysis center in 2016, while a third one earlier this year was due to the reuse of syringes and intravenous drips.