Exploring the HIV/AIDS management and healthcare delivery system in Baluchistan, Pakistan

INTRODUCTION

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) remains a major global public health issue, affecting millions worldwide and driving significant health, social, and economic impacts. In Pakistan, a widespread silence around HIV/AIDS, sustained by social stigma and systemic inaction, has obscured the true scale of the epidemic and left the healthcare system critically unequipped to manage its growing impact.^[1]

HIV/AIDS affects over 38 million people globally, with the highest prevalence and mortality rates in sub-Saharan Africa and low sociodemographic index (SDI) regions. While high SDI areas have seen declines in prevalence and death, resource-limited settings continue to bear a disproportional burden. Key risk factors include unsafe sex, drug use, and partner violence, with young women and men who have sex with men being particularly vulnerable in different regions.^[2] HIV/AIDS treatment success is closely linked to overcoming barriers such as stigma, financial hardship, and limited access to healthcare. These factors can undermine antiretroviral therapy (ART) adherence, delay care, and worsen health outcomes for people living with HIV/AIDS (PLWHA).^[3] HIV-related stigma, internalized, anticipated,or enacted, hinders access to care and ART adherence, often exacerbated by mental health issues, leading to significantly poorer health outcomes.^[4] Urban areas typically have more ART centers, resulting in shorter travel distances and better access. In contrast, rural regions often have fewer facilities, requiring patients to travel long distances, sometimes up to 50 miles in the U.S. rural south or more in sub-Saharan Africa. This is a major barrier to care.^[1] Distance, lack of transportation, and resource limitations are consistently ranked as the top barriers to accessing ART in rural settings. Decentralizing ART services and integrating them into primary care reduces travel burdens and improves outcomes, but rural-urban disparities persist.^[5,6]

Policies on the location and distance of ART centers are critical for ensuring equitable access to HIV/AIDS care. Research consistently shows that distance to ART centers is a major barrier in rural areas, while urban areas generally have better geographic access.^[6,7] PLWHA are more likely to experience depression, anxiety, post-traumatic stress disorder compared to the general populations. Studies report depression rates exceeding 60% and anxiety rates over 40% among PLWH in some settings, with even higher prevalence among women and adolescents.^[8-10]

MATERIAL AND METHODS

This paper is based on the qualitative part of the study. The principal investigator visited the HIV/AIDS control program to conduct the key informant interviews with the healthcare providers, HIV-positive patients, and HIV/AIDS management experts. The present qualitative research study was designed, employing a phenomenological approach with the main purposes to understand the management level of the HIV/AIDS control program in Quetta, Baluchistan, and also the personal perceptions of healthcare providers working in ART centers, and also the barriers faced by HIV-positive patients for healthcare delivery services. The data were collected from three ART centers, which were located in District Headquarters Hospitals. Only three public facilities in Balochistan provide antiretroviral treatment. The main center in Quetta treats local patients and handles complex cases from across the province. Separate centers in Loralai and Turbat serve their respective divisions.

A letter was presented to the Baluchistan AIDS Control Program, Quetta, for permission to conduct interviews at various ART centers in Baluchistan. All interviews were conducted from January 2025 to March 2025. The HIV/AIDS centers were the main sites included AIDS control program, the ART center Quetta, the ART center Loralai, and the Turbat Kech ART center. The above sites are the only centers that provide ART healthcare delivery services. Questionnaire interviews and audio recordings were analyzed with the help of QDA Miner Lite to generate relevant themes and codes [Supplementary Material].

The observations of the principal investigators have also been presented to discuss the gaps identified in the present healthcare delivery systems with regard to HIV/AIDS management in Baluchistan ART centers. This has been done through an ethical approach.

This study received approval from the Health Services Academy Institutional Review Board (000884/HSA/MSPH-2023) and administrative clearance from the Baluchistan AIDS Control Program (01/2024–25/20), with written informed consent secured from every participant before all interviews.

Each interview was conducted by the principal investigator in HIV/AIDS ART centers. Informed consent from healthcare providers, designations, and roles is mentioned, and other confidentiality terms have not been mentioned, and from HIV-positive patients’ ID, gender, age, location, and year. A total of 12 healthcare providers and 18 patients were interviewed, with the number of participants determined by thematic saturation to ensure the collected data fully captured the core challenges and experiences within the healthcare setting.

A semi-structured interview guide [Table 1] was created using existing literature and expert advice, pilot-tested for clarity, and featured open-ended questions on service access, stigma, quality of care, financial burdens, and suggestions for healthcare improvements.

The interviews took 30–45 min each and were audio-recorded in most instances. The recordings were then transcribed into text within 48 h of the interviews. The interviews were based on two main premises under consideration. First, to assess the current capacity of healthcare delivery systems of the AIDS control program and also the management, and same assess the ART centers’ functionality and also evaluate the matters faced by patients during healthcare delivery systems and other gaps in service delivery.

RESULTS

The study evaluated the distribution and profile of healthcare providers alongside HIV-positive patients across critical regions of Baluchistan, with particular emphasis on the ART centers located in Quetta (Bolan Medical Complex Hospital), Loralai (District Headquarters (DHQ) Hospital), and Kech (Turbat DHQ Hospital). These district ART centers are strategically positioned to serve as pivotal hubs for HIV/AIDS treatment within the province, ensuring the delivery of essential healthcare services.

Quetta ART center was established in Bolan Medical Complex Hospital, Quetta, Room NO.3^rd, 4^th, 5^th, Near Cardiac outpatient department (OPD), and Loralai ART center located in DHQ hospital, Loralai, Room NO.3^rd, main OPD, and ART center, DHQ Hospital, Turbat, 1^st room near OPD. Their roles are fundamental in promoting early diagnosis, facilitating access to ART, and driving prevention initiatives, thereby improving healthcare accessibility for people living with HIV/AIDS throughout Baluchistan.

The attached map clearly identifies these ART centers in Quetta, Loralai, Kech (Turbat), visually highlighting their geographic significance in the region’s healthcare infrastructure. A map of Baluchistan highlights the province’s three ART centers, located in only three districts. Green markings cover the remaining 37 districts, illustrating the significant geographical barrier patients from across the province must overcome to access care.

Health authorities report 3,303 people registered with AIDS in the province. This includes 707 women and 90 transgender persons. In the past year, 452 deaths were recorded. The increase from 2,851 cases in 2024 is linked to improved testing and surveillance, leading more individuals to seek care.

Quetta district has the highest burden with 2,164 cases. Other districts report far fewer: Turbat (368), Hub (158), Naseerabad (66), and Loralai (96).

Baluchistan has 37 districts. The province is divided into these districts for administrative purposes, and they are further organized under eight divisions. The whole region has just 3 ART centers and is also strategically away from sister districts those facing financial issues and not able to get the diagnosis and carry the treatment, and support, as shown in Figure 1.

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Figure 1: The geographic location of antiretroviral therapy centers in Baluchistan.

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Table 2 summarizes the demographic and professional composition of healthcare providers involved in HIV/AIDS management across designated facilities. A total of 12 healthcare professionals were documented, including six nurses, four doctors, one pharmacist, and one healthcare management expert, representing a multidisciplinary team equipped to handle the complexities of HIV/AIDS care. Specifically, the Loralai ART Center employs three nurses and two doctors, paralleled by an equivalent staffing structure at the Quetta ART Center at Bolan Medical College. Furthermore, the AIDS Control Program and AIDS Management Center contribute specialized expertise through one pharmacist and one healthcare management expert, respectively, who oversee pharmaceutical management and programmatic strategy.

Table 2 provides a comprehensive overview of the healthcare providers who participated in the study interviews. Research documented demographic and diagnostic details for 18 HIV-positive patients, reflecting a wide age range and representation from both urban and rural communities. Among these patients, there are 6 females, one newborn, and 11 males, The patients who participated in interviews came from diverse demographics in Baluchistan.

The time since diagnosis varies greatly-from as recent as 1 month to as long as 5 years, emphasizing the ongoing difficulties in early detection and sustained care for individuals living with HIV/AIDS. Understanding these patients’ distributions and diagnosis timeline is crucial for tailoring effective interventions and support services.

Table 3 summarizes the patients who participated in interviews, showing their gender, age, location, and years since diagnosis:

Table 4 presents a comprehensive overview of the themes, subthemes, and key points related to healthcare challenges and perspectives in HIV/AIDS management. This table encapsulates the main issues faced by patients and healthcare providers, along with suggested recommendations for improvement. Each entry is accompanied by a unique code for easy reference.

Identified themes highlight critical areas such as barriers to healthcare access, stigma and psychosocial support, quality of care, funding stability, and diverse perspectives from healthcare providers. These foundations are crucial in understanding the complications of HIV/AIDS management and in emerging actual approaches for addressing these challenges.

By exploring these themes and their corresponding subthemes, stakeholders can give valuable insights into the systemic and individual factors affecting HIV/AIDS care. Eventually, notifying policies and involvements aimed at pleasing the eye patients’ outcomes and healthcare delivery. This theme sees the sights of the basic and effective challenges delaying patients’ access to ART services. It highlights issues such as frequent ART center closures due to political unrest, limited geographic availability, particularly in remote areas, and disruptions in medication supply. The need for resilient healthcare infrastructure and service models that guarantee uninterrupted, equitable access to treatment is highlighted.

I walked up to the OPD. My heart sank at the sight of the locked gate. The ongoing disputes between doctors and the government had turned my visit into a frustrating experience. I felt anxious, knowing that my much-needed medication was behind those closed doors.

If I missed my doses, it could seriously hurt my health. Each missed day felt like a setback. While the ART center claims to be independent, it still relies on the government. If it were truly independent, we could get the treatment we need without this interpretation. All I could do was hope for a quick solution to access the vital medication that keeps us healthy. (Bolan Medical complex, Hospital, Quetta [BMC] ART Center).

The need for improved healthcare infrastructure became increasingly clear to me during my visits. The lack of physical availability made it difficult to access the treatment we need. Every time I had to travel long distances just to reach the nearest centers, I felt the weight of the challenges. It was not just about the time spent traveling; it was about the uncertainty and stress that came with it. Patients in remote areas deserve easier access to healthcare services. Expanding ART centers to cover a wider geographic area would make a significant difference, allowing us to receive timely treatment and support without the added burden of long journeys. We need a system that truly meets the needs of all patients, no matter where they live (Chaman district BMC ART CENTER),

DISCUSSION

The findings from this research highlight several critical themes that reflect the complex landscape of HIV/AIDS healthcare delivery in Baluchistan. Each theme illustrates the multifaceted barriers faced by individuals living with HIV/AIDS and underscores the urgent need for targeted interventions to improve access to care and treatment outcomes.^[1] Accessing ART remains a significant challenge, particularly for those in rural areas. The topographical distribution of ART centers is rough, leading to long travel distances that can prevent patients from seeking necessary care.^[11] Political instability, which frequently results in center closures, worsens these challenges, creating a cycle of interrupted treatment and increased health risk. The higher distance delayed the treatment, and gaps, which again increase the vital road.^[12]

The importance of a robust health care set-up is leading to the expansion of ART services, and ensuring their operational consistency is essential for providing equitable access to treatment across the region. The Stigma surrounding HIV/AIDS significantly impacts individuals’ willingness to seek care. The pervasive misconception about HIV/AIDS transmission contributes to discrimination and isolation inside communities. This study highlights the pressing need for community tutoring programs aimed at dispelling mythologies and developing a more understanding situation for those living with HIV/AIDS.^[13]

Participating in mental health services in HIV/AIDS care is central; giving a lecture on the psychological distress caused by stigma can improve patients’ overall outcomes and enhance their willingness to engage with health care services.^[14] While healthcare providers demonstrate professionalism and compassion, resource constraints lead to inconsistencies in the quality of care. Patients frequently express the need for comprehensive support that includes not only medical treatment but also psychological counseling and socio-economic assistance. Mostly, HIV/AIDS during such stigma creates mental issues, especially for survival.^[15]The deficiency of mental health services is mainly about as many patients experience significant emotional challenges related to their diagnosis. A holistic approach to HIV/AIDS care, joining psychological and social support, is important for improving patients’ quality of life and health outcomes.^[16]The sustainability of HIV/AIDS services in Baluchistan is jeopardized by inconsistent funding and limited policy support. Financial shortfalls affect staff retention and medication availability, undermining the overall effectiveness of HIV care. The study calls for a strengthened governance framework and a sustainable funding mechanism, emphasizing the importance of collaboration among government entities, NGOs, and community organizations. Such partnerships are vital for developing a cohesive response to the HIV/AIDS epidemic and ensuring that individuals living with HIV/AIDS receive the comprehensive care they need.^[17,18]

CONCLUSION

This study highlights the strengths and challenges of HIV/AIDS healthcare in Baluchistan, emphasizing the commitment of multi-disciplinary teams despite resource limitations. Key barriers include political unrest and stigma, which hinder treatment continuity and patient adherence, gaps in mental health support, and unstable funding threaten service sustainability. Addressing these issues through an integrated approach and community education is essential for improving health outcomes for those living with HIV/AIDS in the region.