NGO casts doubt on credibility of HIV projections in Pakistan

ISLAMABAD: Pakistan’s HIV response is being guided by estimates that may not fully match conditions on the ground, with projections suggesting around 370,000 people are living with HIV in the country, according to Nai Zindagi, which has questioned how closely these figures reflect actual epidemiological trends.

The organisation said much of the concern relates to widely cited UNAIDS projections indicating a rising HIV burden in Pakistan. It said these estimates rely heavily on data from rounds of the Integrated Biological and Behavioural Surveillance (IBBS), which were financed by the Global Fund. According to Nai Zindagi, experts have identified serious methodological weaknesses in these surveys, raising doubts about the reliability of projections that continue to shape policy decisions, funding priorities and public perception.

Speaking to Dawn, Nai Zindagi Executive Director Malika Zafar said the IBBS did not cover the general population.

"It focuses entirely on key populations, including female sex workers, transgender persons, men who have sex with men, and people who inject drugs (PWID). These findings are often extrapolated into sweeping national projections despite HIV prevalence in Pakistan’s general population remaining around 0.05 per cent," she said.

Ms Zafar cited Karachi as what she described as the clearest example. She said Nai Zindagi has been working with PWID in the city since 1989 and, with Global Fund support since 2011, has run outreach services across nearly 500 hotspots in 62 districts. According to her, the 2011 IBBS estimated about 16,544 PWID in Karachi, a city of more than 20 million people. She said Nai Zindagi expanded its outreach on the basis of that estimate, but field operations consistently found far fewer individuals.

She said the 2016 IBBS estimate for Karachi rose to 24,036 PWID. According to Ms Zafar, mapping data from that survey showed similar locations appearing repeatedly under similar names, which inflated the count. Despite broad field coverage, she said Nai Zindagi’s verified programme data identified around 5,500 active individuals across all functioning hotspots in Karachi. She added that requests for data cleaning and reconciliation were reportedly not acted upon, and that the inflated figures were then fed into the UNAIDS Asian Epidemic Model and presented publicly as epidemic projections.

"Projections are statistical estimates, not confirmed epidemiological realities,"she said.

Ms Zafar said concerns deepened with the 2025 IBBS round. She said the survey, using reverse tracking and geolocated hotspot verification, identified 2,438 PWID in Karachi, while Nai Zindagi independently reported 3,169 individuals. She added that about 98 per cent of mapped hotspots matched Nai Zindagi’s verified locations.

"Yet Bayesian synthesis methods were applied with heavy weighting given to the inflated 2016 estimates. This produced a final projection of nearly 25,000 PWID in Karachi, almost ten times the figures generated by field data from the 2025 IBBS," she said.

According to Ms Zafar, mapping exercises had identified and verified populations and hotspots, but the inflated projections did not correspond to any identifiable location or population. She said the methodology had mathematically created phantom populations disconnected from field realities.

"Inflated estimates distort resource allocation, misdirect prevention strategies, weaken confidence in surveillance, and undermine the credibility of Pakistan’s HIV response internationally. When paired with elevated prevalence estimates, even small distortions in population size exponentially magnify national projections," she said.

Ms Zafar said Pakistan does face genuine HIV challenges, but argued that sound public health policy depends on credible evidence. "Given the devastating implications of inflated estimates, there is an urgent need to revisit the methodology behind population size estimation and Bayesian synthesis within the IBBS framework," she said.

She also called for independent validation exercises, including repeat mapping, to test estimates against field realities and restore confidence in the data used to guide Pakistan’s HIV response.

Beyond policy and programming, Ms Zafar said inflated projections were also affecting Pakistan’s image abroad.

"The country’s HIV response is increasingly viewed globally through alarming epidemic estimates that bear little resemblance to on-the-ground realities. This has projected Pakistan as facing an uncontrolled epidemic that field evidence cannot substantiate," she said.

"Accurate surveillance is essential for protecting the credibility of Pakistan’s public health institutions and ensuring international representation is based on evidence," she added.