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Haider Warrauch and Eitezaz Mahmood, AFPAK channel, Foreign Policy Magazine: Checking the spread of AIDS in Pakistan

Checking the spread of AIDS in Pakistan
by Haider Warrauch and Eitezaz Mahmood, August 25, 2011

In Pakistan, you could probably live for years and never meet anyone with HIV/AIDS. Yet the fact that the virus is not often in the public eye does not mean that HIV/AIDS is not a problem in Pakistan. It is known to infect tens of thousands of Pakistanis, a figure that is certainly a gross underestimate due to both sexual taboos surrounding the disease and the often low social status of many of its victims. And while HIV/AIDS does not attract the kind of notice it once did in the developed world, in Pakistan the scourge has only recently been given more attention.

HIV/AIDS is believed to have been introduced to Pakistan by migrant workers returning from the Middle East. These workers, who went to the Gulf states on work permits, would frequently engage in risky behavior while abroad. Workers, however, needed medical screening in order to renew their work permits, and if one tested HIV-positive during screening, he was sent packing on the first flight back home — in most cases without even being informed of his HIV status. The first confirmed cases of HIV/AIDS were discovered in Pakistan in 1987. At that time, the public perception was that HIV/AIDS would not become endemic in Pakistan because of the country’s strict religious and cultural norms. By 1999, three-fourths of HIV infections occurred among migrant workers returning from Arab Gulf states. In the late 1990s, however, cases of HIV/AIDS began to steadily increase among Pakistani sex workers, prison inmates, truck drivers (who frequently employ the services of prostitutes), and, especially, injecting drug users (IDUs). And in June 2003, after an IDU prisoner tested positive for HIV, local authorities found 27 percent to be HIV-positive. After the discovery of this outbreak, similar occurrences among IDUs were documented across the country. The unsafe injection practices of IDUs and their lack of knowledge regarding HIV helped fuel a steady rise in HIV-positive IDUs over the last decade. They remain, by most observations, the core group affected by the HIV outbreak in Pakistan.

HIV has also spread to other high-risk groups, particularly male homosexuals, categorized in public health terms as “men who have sex with men” (MSM). Many different groups in Pakistan qualify as being MSMs. Once occupying elite positions as jesters, advisors, and bodyguards in the courts of kings, hijras, or male transvestites, are now among the most oppressed and loathed groupsin Pakistan. Hijras are often the receptive partner in intercourse, making them particularly at risk for HIV infection. Similarly, zenanas are married males who secretly identify as women. Giryas are the male “husbands” of hijras and zenanas, who often do not know of their partners’ promiscuity, further increasing their chances of infection. While homosexuality is by most indications not rampant in Pakistan, transvestites are a particularly visible group in public spaces. Other MSM populations include maalishias — boys who are masseurs but may also sell sex. Already marginalized in Pakistani society, the 1979 Hudood Ordinance, enacted under military ruler Muhammad Zia-ul-Haq, declared homosexuality a criminal offense, driving MSMs further underground. That these groups live largely outside the umbrella of the state as well as the goodwill of the people presents a significant barrier to those trying to deliver health care to these men.

According to the Asian Epidemic Model, HIV/AIDS concentrates first among high-risk groups, but then makes its way to the general population through bridging groups who are in sexual contact with high-risk individuals. While the bridging population is difficult to characterize, the wives of IDUs, clients of sex workers, and truck drivers all frequently engage in unprotected sex with high-risk groups. The bridging population, however, is not the only route for HIV to reach the general population; 6.8 percent of IDUs donate blood, yet less than half of blood transfusions are screened for diseases in Pakistan. In the nightmare scenario that the HIV virus reaches the general population, it will be very difficult, if not impossible, to contain.

Thankfully, HIV/AIDS has been recognized as a health-policy priority in the country. The Pakistani government has collaborated with NGOs to provide condom delivery, needle exchange programs, drug rehabilitation programs, and treatment for those at risk of HIV. HIV/AIDS interventions between 2008 and 2009 reportedly reached more than 30,000 IDUs, 25,000 male and hijra sex workers, 12,000 female sex workers, and 50,000 truckers. Furthermore, a recentSupreme Court ruling gave hijras complete citizenship rights as a “third sex,” allowing them access to social welfare and financial support programs. This is a major step forward for a group historically ostracized and considered undesirable. And from 2008 to 2009, the percent of IDUs reached through the prevention programs spiked from 15.5 percent to 53 percent. Similarly, the percent of IDUs reporting use of sterile injecting equipment has increased from 30 percent to 80 percent in the past three years alone.

Despite these successes, health-care workers still have much work ahead in order to achieve their goal of halting and reversing the spread of HIV in Pakistan. Current efforts are not reaching a significant proportion of the targeted population, and despite the large increase in those reached through prevention programs, it is still not enough to prevent a genuine outbreak. However, the greatest obstacle in the way of those wanting to expand the epidemic response remains a lack of funding. This has been further strained since the floods in 2010, which diverted most available funds that may have otherwise gone to checking the spread of the disease.

Like most other public health challenges, responses to the HIV/AIDS outbreak are deeply intertwined with the prevailing social and geopolitical landscape in Pakistan. Dealing with HIV/AIDS in particular brings to the surface taboos such as sex, gender identity, drug abuse, and homosexuality, issues that people in Pakistan are wary to address. However, such cultural change is ultimately necessary if Pakistan is to deal with HIV/AIDS holistically, before this simmering crisis boils over.

Haider Warraich, M.D., is a research fellow at Harvard Medical School and author of the novelAuras of the Jinn. Eitezaz Mahmood is an undergraduate student in Northwestern University.

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