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MAM SHAHEERA ADIL AISHA MEHMOOD
TABLE OF CONTENT
Serial No. Context
I take immense pleasure in thanking Mam Shaheera Adil for having permitted me to carry out this project work.
I wish to express my deep sense of gratitude to my Internal Guide, Ms Madeeha Noor for her able guidance and useful suggestions, which helped me in completing the project work, in time.
Finally, yet importantly, I would like to express my heartfelt thanks to my beloved parents for their blessings, my friends/classmates for their help and wishes for the successful completion of this project.
Pakistan runs the risk of experiencing the rapid increase in HIV/AIDS among vulnerable groups seen elsewhere.
State of the epidemic:
According to UNAIDS estimates, some 70,000 to 80,000 persons, or 0.1 percent of the adult population in Pakistan, are infected with HIV. Officially reported cases are, however, much lower. Until September 2004, only some 300 cases of full-blown AIDS and another 2300 cases of HIV infection were reported to the National AIDS Control Program. As in many countries, underreporting is due mainly to the social stigma attached to the infection, limited surveillance and voluntary counseling and testing systems, as well as the lack of knowledge among the general population and health practitioners. Until recently, Pakistan was classified as a low-prevalence country with many risk factors that could lead to the rapid development of an epidemic. However, recent evidence indicates that the situation is changing rapidly. In 2004, a concentrated outbreak of HIV was found among Injecting Drug Users (IDUs) in Karachi, where over 20 percent of those tested were found to be infected. High levels of HIV infection - 4 percent - were also found among men who have sex with men (MSM) in the city. The infection rate among Hijras was 2 percent. Nonetheless, HIV prevalence among other high risk groups in Karachi and all vulnerable populations in Lahore is still low - below 1 percent. The findings underline the risk of an escalating epidemic. They point to the presence of significant risk factors such as the very low use of condoms among vulnerable populations including female sex workers (FSW), MSMs, truckers, and Hijras, as well as the low use of sterile syringes among IDUs. They also reveal an alarmingly high prevalence of syphilis among Hijras - 60 percent in Karachi and 33 percent in Lahore - which increases the risk of HIV infection.
There are serious risk factors that put Pakistan in danger of facing a rapid spread of the epidemic if immediate and vigorous action is not taken: Outbreaks among Injecting Drug Users (IDUs): The number of drug dependents in Pakistan is currently estimated to be about 500,000, of whom an estimated 60,000 inject drugs. An outbreak of HIV was discovered among injecting drug users in Larkana, Sindh, where, out of 170 people tested, more than 20 were found HIV positive. In Karachi, a 2004 survey of Sexually Transmitted Infections among high
risk groups found that more than one in five IDUs was infected with HIV. These represent the first documented epidemics of HIV in welldefined vulnerable populations in Pakistan. They serve as confirmation of the threat that HIV poses to Pakistan and validate the premise of the country’s recent Enhanced HIV/AIDS Program. HIV Infection among Men who have Sex with men (MSM): Lahore had an estimated 38,000 MSM in 2002. The MSM community is heterogeneous and includes Hijras (biological males who are usually fully castrated), Zenanas (transvestites who usually dress as women) and masseurs. Many sell sex and have multiple sexual partners. The 2004 STI survey found that 4 percent of MSMs in Karachi were infected with HIV, as were 2 percent of the Hijras in the city. Syphilis rates were also high with 38 percent of MSMs and 60 percent of Hijras in Karachi infected with the disease. Unsafe Practices among Commercial Sex Workers (CSW): Commercial sex is prevalent in major cities and on truck routes. Behavioral and mapping studies in three large cities found a CSW population of 100,000 with limited understanding of safe sexual practices. Furthermore, sex workers often lack the power to negotiate safe sex or seek treatment for STIs. Recent findings indicate that although HIV prevalence remains below 1 percent, female sex workers (FSWs) and their clients report low condom use. Less than half the FSWs in Lahore and about a quarter in Karachi had used condoms with their last regular client. Inadequate Blood Transfusion Screening and High Level of Professional Donors: It is estimated that 40 percent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. In 1998, the AIDS Surveillance Center in Karachi conducted a study of professional blood donors—people who are typically very poor, often drug users, who give blood for money. The study found that 20 percent were infected with Hepatitis C, 10 percent with Hepatitis B, and 1 percent with HIV. About 20 percent of the blood transfused comes from professional donors. Large Numbers of Migrants and Refugees: Large numbers of workers leave their villages to seek work in larger cities, in the armed forces, or on industrial sites. A significant number (around 4 million) are employed overseas. Away from their homes for extended periods of time, they become exposed to unprotected sex and are at risk for HIV/AIDS. Unsafe Medical Injection Practices: Pakistan has a high rate of medical injections - around 4.5 per capita per year. Studies indicate that 94 percent of injections are administered with used injection equipment. Use of unspecialized needles at medical facilities is also widespread. According to WHO estimates, unsafe injections account for 62 percent of Hepatitis B, 84 percent of Hepatitis C, and 3 percent of new HIV cases.
Low Levels of Literacy and Education: Efforts to increase awareness about HIV among the general population are hampered by low literacy levels and cultural influences. In 2001, the illiteracy rate of Pakistani women over 15 years old was 71 percent. Vulnerability Due to Social and Economic Disadvantages: Restrictions on women's and girls’ mobility limits access to information and preventive and support services. Young people are vulnerable to influence by peers, unemployment frustrations, and the availability of drugs. In addition, some groups of young men are especially vulnerable due to the sexual services they provide, notably in the transport sector. Both men and women from impoverished households may be forced into the sex industry for income.
National response to hiv/aids:
Government. Pakistan’s Federal Ministry of Health initiated a National AIDS Prevention and Control Program (NACP) in 1987. In its early stages, the program was focused on diagnosis of cases that came to hospitals, but progressively began to shift toward a community focus. Its objectives are the prevention of HIV transmission, safe blood transfusions, reduction of STI transmission, establishment of surveillance, training of health staff, research and behavioral studies, and development of program management. The NACP has been included as part of the government's general health program, with support from various external donors. As the government has indicated in the recent scaling up of its response to HIV/AIDS, more needs to be done. A special focus on reducing the exposure of high-risk groups is urgently required. Improving skills, building capacities, strengthening advocacy, and increasing participation is needed not only in the area of health, but in several sectors, including education, labor, law and order, etc. In early 2001, the Government of Pakistan, through a broad consultative process, developed a national HIV/AIDS Strategic Framework that sets out the strategies and priorities for effective control of the epidemic. Non-Governmental Organizations (NGOs). At least 54 NGOs are involved in HIV/AIDS public awareness and in the care and support of persons living with HIV/AIDS. These NGOs also work on education and prevention interventions targeting sex workers, truck drivers, and other high-risk groups. NGOs serve as members of the Provincial HIV/AIDS Consortium, which has been set up in all four of Pakistan’s provinces to coordinate HIV/AIDS prevention and control activities. Although NGOs are active in HIV/AIDS prevention activities, it is believed that they are reaching less than 5 percent of the vulnerable population. Donors. UNAIDS has established a Theme Group and a Technical Working Group on HIV/AIDS to coordinate the response of United Nations Agencies and to provide assistance to the government in the 6
strategic development of activities. The theme group includes UNAIDS, WHO, UNICEF, UNFPA, UNDP, UNDCP, UNESCO, ILO, the World Bank, national and provincial program managers, and representatives of nongovernmental organizations.
Pakistan still has a “window of opportunity” to act decisively to prevent the spread of HIV. The banks says that although the estimated HIV burden is still low at around 0.1 percent of the adult population, there has been an outbreak of HIV among injecting drug users (IDUs) in Sindh. Without vigorous and sustained action, Pakistan runs the risk of experiencing the rapid increase in HIV among vulnerable groups seen elsewhere. According to UNAIDS estimates, about 85,000 people, or 0.1 percent of the adult population in Pakistan, are infected with HIV. Officially reported cases are much lower, however. As of September 2004, only 300 cases of AIDS and 2,300 cases of HIV infection were reported to the National AIDS Control Programmed. As in many countries, underreporting is due mainly to the social stigma attached to the infection, limited surveillance and voluntary counseling and testing systems, as well as the lack of knowledge among the general population and health practitioners.
HIV-infected workers deported from the Gulf States: impact on southern Pakistan
The first case of AIDS was confirmed in Pakistan in 19871. While the prevalence of HIV is still low in Pakistan, its geographic proximity to India, a country experiencing a severe HIV/AIDS epidemic, and several prevalent lifestyle risk factors make Pakistan a high-risk location for the diffusion of HIV. HIV risk factors in Pakistan include internal and external migration, commercial sex work, and failure to use condoms, male-to-male sex, and re-use of contaminated needles, particularly in the informal health-care sector. Judging from surveillance data, sex is the predominant mode of transmission and most reported HIV cases to date are among men.
Sindh is the second most populated province of Pakistan with 35 million persons (25% of the population of Pakistan). Sindh has the highest number of reported cases in the country: 45% of all AIDS cases and 32% of all HIV-positive cases (without AIDS). The capital of Sindh is Karachi, which in addition to being the most urbanized city in the country, is the only major commercial seaport in Pakistan. Its population is 10 million and it hosts 70% of the country's factorybased industry. A large number of Pakistani citizens are employed in the Gulf States (e.g. Saudi Arabia, Kuwait, and United Arab Emirates). In Saudi Arabia, 27% of the population is foreign nationals who make up over half of the work force. Before being granted a resident permit, foreign nationals entering the Gulf States are tested for HIV in their country of origin. Resident permits are not granted to HIV-positive individuals. Foreign nationals are required to renew their work permit and their HIV test every 2 years. Anyone found HIV positive is deported immediately to his country of origin. Treatment or counseling is rarely provided..
The data collected for this paper originated from 10 HIV surveillance centers established in 1995 by the Sindh AIDS Control Programmed. HIV testing in Pakistan is done largely on a voluntary basis. The Sindh AIDS control programmed has established an outreach programmed towards public and private health-care practitioners to enhance the practice of HIV testing among their high-risk and/or symptomatic patients. HIV-infected deported workers are reported to the AIDS control programmed by the Pakistani immigration services but most deported workers report on their own to an HIV surveillance centre for diagnosis confirmation. The 10 Sindh HIV surveillance centers offer free HIV testing, condoms, and pre- and post-test counseling. An enzyme-linked immunosorbent assay (ELISA) for HIV (Abbott Park) is performed at the central laboratory of the Sindh AIDS Control Programmed in Karachi. The Sindh AIDS Control Programmed follows the World Health Organization (WHO) recommendation for costefficient HIV testing. A positive ELISA test is confirmed positive with a second positive ELISA (Behring) and a positive agglutination test (Serodia, Fuji Rebio kit). HIV-positive patients are referred to the Dow Medical College for medical evaluation and treatment of opportunistic infections (mainly tuberculosis). Due to their high price and difficulties in treatment adherence in a resource-poor environment, anti-retroviral treatments are used rarely in Pakistan.
From 1996 to 1998, 86 HIV/AIDS cases were reported to the Sindh AIDS Control Programmed. All available cases were investigated
(n=79) and among them, 73% were overseas workers deported from the Gulf countries, 7% were wives of the same deported workers, 9% were foreigners, and 11% had locally acquired the infection through other means (e.g. intravenous drug users, commercial sex workers, prisoners). Returned workers represented 61 to 86% of reported cases in any given year during the 1996–1998 time periods. Although investigated cases were not randomly selected, it is nonetheless likely that they are reasonably representative of the overall number of reported cases. It is also likely that the inhabitants of Karachi were over-represented in our study as compared to the inhabitants of the other parts of the Sindh province.
HIV and homosexuality in Pakistan
In Pakistan, seven times more men are reported to be infected with HIV than women. Among the Pakistani population, modes of HIV transmission include infection through sexual contact, contaminated blood and blood products, injecting drug use, and mother-to-child transmission. Although most sexual transmission of HIV results from unsafe heterosexual contact, homosexual and bisexual contact also represents important modes of transmission. According to unpublished reports, the prevalence of HIV among homosexual and bisexual Pakistani men is reaching alarming proportions. We describe the Pakistani homosexual and bisexual culture, review statistics regarding HIV prevalence and risk behavior, and identify areas of improvement in the HIV policy with specific focus on men who have sex with men.
Educating the power: HIV/AIDS and parliamentarians of Pakistan
The recent HIV epidemics recorded amongst the Injection Drug User community in various cities of Pakistan have mobilized the health authorities, particularly the international agencies, into realizing HIV as an actual ground reality in this South-East Asian Republic. To prevent a deluge of HIV incidence, various initiatives have been launched. The Pakistani health authorities and their fellow Parliamentarians are being urged to play their part to fight up to this challenge, keeping in mind the dearth of any formal research efforts in Pakistan targeted towards HIV/AIDS policy formulation. The role of prevention as pertains to HIV spread in this country becomes all the more crucial in view of its dire economic and societal indices. Therefore, Pakistani Parliamentarians are being encouraged to understand the dynamics of HIV/AIDS spread in Pakistan through a series of informative seminars, ultimately geared to aid in the formulation of a National HIV/AIDS Policy.
To help Pakistan prepare its HIV/AIDS policy, a diverse preliminary forum was organized two years ago at Islamabad, the capital of Pakistan, in mid-January, 2005. Organized under the umbrella of UNAIDS and Parliamentarians for Global Action (PGA), the seminar served to bring together a worldwide network of over 1300 Parliamentarians from 110 National Parliaments, including legislators from India, Pakistan, Bangladesh, Nepal and Sri Lanka. The objectives were to empower the Parliamentarians to truly understand the extent of the virus in South Asia, outline strategies proven to work in combating the virus, and, most importantly, address the roles Parliamentarians can play to increase political commitment for addressing the epidemic. Both the Pakistani Prime Minister and the UN's Special Envoy were present at this occasion. In continuation of the Islamabad Declaration, PGA embarked upon a series of HIV sensitization and awareness seminars for Parliamentarians, specially tailored to address the policy needs of
each of Pakistan's four provinces. The first Provincial Parliamentary Seminar on HIV, then, took place in Karachi, the capital of the province of Sindh, in January 2006. The fact that the implementation of primary healthcare, education and reproductive health services falls under the authority of provincial legislatures according to the Pakistani constitution, the role of the Provincial Parliamentarians becomes all the more crucial. Various reports of HIV cases in IDUs have emerged from Sindh. The provincial seminar in Sindh provided a rare opportunity for Parliamentarians of rival parties to come together on the HIV/AIDS issue. All four provinces were adequately represented, with special envoys from Sri Lanka and Canada also present. The seminar objectives included enhancing the Parliamentarians' understanding of their own provinces, familiarizing them with priority areas of intervention and outlining a plan of action at both provincial and district levels. Invaluable discussions took place where the people-in-power debated over the formulation of laws and policies against the virus. The second installment of these awareness campaigns for the Parliamentarians was organized by PGA in December 2006, in Lahore, the capital of the province of Punjab, the most populous province of Pakistan. Apart from serving as a platform for discussion and exchange of ideas on prevention strategies for the spread of the virus, the seminar provided an opportunity for the members of each provincial group to share reviews of action plans previously formulated by each province during the Karachi seminar. This enabled a reassessment and subsequent reinforcement of commitment to the cause. Spending capital and organizing research garnered towards HIV/AIDS policy development is a scarce commodity in Pakistan. There are no public funds available to channel in this direction, but this should be understandable considering Pakistan's faltering economic and educational standards (the country ranks 77 on the Human Poverty Index). However, all is not bleak, and international organizations including UNAIDS and PGA are making serious efforts to establish and engage research targeted specifically towards policy development. PGA is making a commendable effort in Pakistan and South Asia to improve HIV awareness on a governmental level. PGA plans to target each of the four Pakistani provinces individually, allowing the Parliamentarians to view and evaluate the HIV policy issues unique to each province. After Sindh and Punjab, the next two provinces in line are Balochistan and the North-West Frontier Province. The plan of action PGA have chalked out for themselves is thorough and systematic. It also, however, comes with a full bag of obstacles and challenges.
Right from its inception, Pakistan, a former British Colony, has been in an out of the vortex of political upheavals - its fate continually tossed between the feudal lords and the military. The consistent absence of true democratic spirit in the country has, consequently, generated a hiatus between the populace and the Parliamentarians. In the political scenario of Pakistan, the dogma of democracy stems from a very unique perspective. Carefully guarded legacies of family traditions ensure that power is handed down within a select group of individuals. The welfare of the general populace then usually is a circumstance, resultant of the interplay of custom, authority, and tribal wisdom. Pakistan has come a long way since its first reported HIV case in 1987. UNAIDS latest figures estimate the number of cases bordering 96 thousand. Underreporting and limited surveillance means that the actual number of infected is much higher. The social and health demographics of the county are also extremely distressing, with a low literacy rate (UNESCO estimates female adult literacy to border around 40% in 2006) combined with a burgeoning population growth rate. All in all, the nation already has enough problems on its hands before letting the scourge of HIV jump in as well. In the recent few years, there have been incidences recorded of HIV outbreaks from all major cities of Pakistan, including Lahore, Karachi and Hyderabad. This rapid spread of HIV has certainly shaken the earlier otherwise dormant status-quo in this predominantly Muslim nation, which had been relatively safe from a steep rise in HIV infections for almost two decades, in contrast to its neighbor, India. The patterns of HIV transmission in Pakistan are similar in many ways to other parts of Asia. The virus traverses the barrier from high-risk communities to the mainstream population. Once this transmission jump has occurred, the increase in HIV incidence is swift and uncontrollable. Along a similar pattern, India experienced an explosive spread of HIV/AIDS in the early 90s. Ironically, the same HIV risk communities, mainly Injection Drug Users (IDUs), that fueled India's epidemic, are showing a steady surge of HIV prevalence in Pakistan as well. In Pakistan, any hope of winning the battle against HIV lies on the prevention front. The relatively low prevalence of HIV infected individuals presents a window of opportunity for the implementation of preventive strategies. Severe lack of resources and expertise in treating the disease threatens to spread the virus into the mainstream population. Once the transmission jump occurs, Pakistan will be fighting a lost battle. The only promise of initiating a change is offered through the involvement of the people who have the power to bring the change - the Parliamentarians of Pakistan. Ironically, the HIV
initiatives from PGA are the first examples of rally points for all Parliamentarians, regardless of party or demographic advocacy, a rarity in the tormented Pakistani political setup. More effort needs to be made in the same direction. Pakistani politicians must realize that issues such as HIV/AIDS require them to come together with a concerted sincerity that rises above the mandate of their individual political affiliations, and considers the issues in a national and global perspective.
A situational analysis of HIV and AIDS in Pakistan
HIV (Human immunodeficiency virus) transmission has been reduced by protected sex and screening of blood products and other body fluids in the developed countries. It has been reported that Pakistan is at high risk of HIV/AIDS infection but presently the prevalence rate is considerably low. The number of reported cases of HIV/AIDS in Pakistan has been continuously increasing since 1987. By 2010 the total number of registered cases has reached to 6000 and this figure is on the rise with the passage of time. Some serious strategies must be implemented to control this deadly disease.
Situation in Pakistan
Pakistan's first HIV/AIDS case was detected in 1987. The number has been increased according to the annual report of Pakistan National AIDS Control Program (NACP). Pakistan, located in South Asia, is the sixth most densely packed country populated by 168.79 million people by the end of 2009. It has four provinces "Sind, Punjab, Khyber Pakhtoonkhwa and Baluchistan. India, China, Iran and Afghanistan are the neighboring countries of Pakistan. The region has a literacy rate of only 54%. Like other Asian countries Pakistan is also HIV epidemic, characterized by different risk factors Formerly Pakistan was considered to be a low prevalence country, but now it is in the group of "Countries in Transition" with a concentrated epidemic among high risk groups, where the AIDS problem is increasing since last five years, according to the private newspaper The News and NACP NIH. The number of infected persons might be running in millions if proper screening is carried out. The behaviors conducive to the spread of HIV infection to young people are curiosity about sex and drugs, negative peer pressure, and economic frustration in Pakistan. Widespread poverty, significant power imbalances in men and women, labor migration, lack of any system to check the HIV positive reported 13
persons, indiscriminate transfusion of unscreened blood, rising number of drug addicts and low condom use rates, are the serious risk factors that put the country in danger of facing a rapid spread of HIV. 9% of the tested injecting drugs users (IDU's) were found to be HIV positive in 2005-2006, this percentage increased to 15.8% in 2006-2007, and it exceeded 20% in 2007-2008. 97,400 cases of HIV/AIDS were estimated in 2009 and more than 6,000 cases are registered till now (2010). Till March 2010, 3325 patients were registered at national AIDS control center NIH Islamabad. 1425 patients are on ARVS. The geographic trend of the epidemic has recently expanded from major urban cities and provincial capitals to more rural town and smaller cities. Although national adult HIV prevalence in the general population remains < 0.1%, exceptions were observed as in Jalalpur Jattan (Gujrat) where 90 HIV positive cases were found, out of 342 samples from the general population that included a large number of sex-migrant workers. Among many factors, one important factor attributing to this development is unsafe injecting practices in formal and informal healthcare settings. The mode of HIV/AIDS transmission in Pakistan is largely heterosexual (52.55%), the most commonly reported modes of transmission are contaminated blood or blood products (11.73%). According to AIDS Asia HIV wide spread is contributed by intravenous drug users (IDU's) (2.02%), male-to-male or homosexual relations (4.55%), mother-to-child transmission (2.2%) and transmission due to undetermined origin (26.9%) along with other factors. The major concern in Pakistan is the recent studies which have put the figures in HIV infected IDUs up to 2.5-3.5% during 2004-05. Many of these IDUs are also professional blood donors in a country with inadequate blood transfusion screening; only 50% of the transfused being screened for HIV. According to the study conducted by Pakistan Demographic Health Survey, 2007-08, from all the four provinces of Pakistan along with FATA and AJK. In the light of the above said study, total 1998 patients were identified as HIV infected out of which, 1765 were HIV positive only while 233 developed AIDS. The study above said study showed that HIV is most prevalent in the Sindh province while least prevalent in AJK. 86.8% of reported HIV positive cases are found to be men. Furthermore 51.88% of the HIV infected men fall within the age group of 20-40 years. 24.59% of the reported cases are of unknown origin, 13.20% are females, and 45.10% of the total HIV carriers acquired the disease through sexual contact. Pakistan's National AIDS Control Program (NCP) is one of the pioneer institutions providing free treatment to any person found to be suffering from AIDS through its 20 AIDS Treatment Centers all over the country.
1. In a country with low literacy rate one should expect low level of awareness about HIV/AIDS. Awareness needs to be created at all levels especially in rural areas. 2. The government should know its responsibilities and should provide the necessary legal and regulatory frame work for dealing with this silent killer disease. 3. This disease is spreading continuously without knowing the boundaries. Further strategies must be implemented. Otherwise it will be impossible to get rid of this lethal wave.
HIV/AIDS In Pakistan: The Battle Begins
Pakistan, the second most populous Muslim nation in the world, has started to finally experience and confront the HIV/AIDS epidemic. The country had been relatively safe from any indigenous HIV cases for around two decades, with most of the infections being attributable to deported HIV positive migrants from the Gulf States. However, the virus finally seems to have found a home-base, as evidenced by the recent HIV outbreaks among the injection drug user community. Extremely high-risk behavior has also been documented among Hijras (sex workers) and long-distance truck drivers. The weak government response coupled with the extremely distressing social demographics of this South-Asian republic also helps to compound the problem. The time is ripe now to prepare in advance, to take the appropriate measures to curtail further spread of the disease. If this opportunity is not utilized right now, little if at all could be done later.
Pakistan, the world's second most populous Muslim nation, has started to finally experience and confront the HIV/AIDS epidemic. Largely portrayed as having free of this menace till now, this SouthAsian republic seems to be following in suit with its HIV-havocked neighbor, India. With isolated outbreaks being reported all over the country, time already seems to be running out for the sixth most populous country in the world.
The first reports of HIV in Pakistan in 1987 implicate contaminated blood transfusions as one of the culprits. The other route alludes to expatriates or Pakistanis settled abroad. These seem to be the more important risk factor for acquisition of HIV, as demonstrated amply by the fact that around 70% of the total positive HIV cases from a sample of over 15,000 individuals over a period of six years (1986– 1992) fell into this category. The bulk of the infected were deported workers from the Gulf States. Pakistan, as compared to its neighbors, has remained relatively safe from any indigenously acquired cases of HIV for about two decades. The situation however changed in 2004 when Pakistan experienced its first full-fledged HIV outbreak. In the remote desert town of Larkana, the HIV bubble-burst took place amongst the injection drug user (IDU) community. What this basically meant was that the virus had finally found a home-base, as evidenced later by outbreaks all over the nation.
The HIV/AIDS epidemic in Pakistan is following along the same atypical lines as it has done so far in the rest of Asia. Starting from isolated high-risk population subgroups, the virus jumps the barrier to cross into the mainstream general populace. Once this barrier is crossed, little if at all anything can be done to prevent a complete HIV onslaught. Similar to its south-east Asian neighbors, the greatest risk for the spread of HIV in Pakistan stems from IDU. Currently estimated at over 180,000 in number, the ongoing strife in Afghanistan, the world’s largest poppy producing country, seems only to swell up this number even more in the future. IDU all over the country have started recording alarmingly high rates of HIV. According to the latest figures released by the National AIDS Control Program of Pakistan, HIV/AIDS prevalence among IDUs has jumped from 0.4% in December 2003 to 7.6% in 2004. However, in Larkana, where Pakistan's first HIV outbreak among IDU was reported, the number approached an astounding, twenty-seven percent. After the Larkana episode, HIV has been documented among IDU all over Pakistan. Currently, IDU do not comprise the bulk of drug users in Pakistan. The number of IDU is bound to increase in the near future, and as this happens, the relative cases of HIV/AIDS will also rise. The first hurdle in the spread of HIV seems to be already traversed. Sex workers in Pakistan represent the second most serious threat for HIV transmission. The government refuses to accept illicit sex underway in the country, although there are established prostitution centers in all the major cities of Pakistan. The so-called 'red-light'
areas, in addition to female prostitutes, also house Hijras – male transvestites. These Hijras provide valuable insight into HIV demographics, as data pertaining to female commercial sex workers is very limited. Reports suggest that the HIV prevalence among Hijras in Karachi, a city of 13 million people in southern Pakistan, approximates around 4%. The situation is bound to be even worse in the rural parts, particularly in the Pathan-dominated northern Pakistan, where homosexuality is socially tolerated. The majority of men having sex with men in Pakistan are married, which brings into light their possible potential as acting as a bridge to the general population. Truck drivers are also a very important subgroup, primarily because of their role in fuelling the HIV epidemic in neighboring Madras, India. In a survey done in Lahore, Pakistan's central Hub for long-distance truckers, over 49% of them reported having sex with another man. The possibility of horizontal ellipsis across the border from India has also been raised. Once the high-risk populations have acquired the virus, it is only a matter of time before the general populace falls prey to it. IDU, commercial sex workers, truck drivers, etc., facilitate in bridging this gap. What is alarming is the fact that once the virus moves from the urban population to the rural population, the effect will be much more catastrophic, not only because the bulk of the Pakistani population resides here (only 34% lives in urban areas) but also due to almost non-existent healthcare-facilities.
Decades of corruption and poor planning of resources have translated into a fight for Pakistan's very own continued existence. Keeping this in mind and the horde of other problems currently encountering Pakistan, any efforts directed towards prevention and control of HIV/AIDS are quite laudable. The bulk of the credit in this regard goes to the private sector. Over 50 non-governmental organizations (NGO) are working to improve the HIV/AIDS status quo in Pakistan. Their work ranges from providing needle-exchange programs for IDU to spreading awareness about HIV/AIDS to the masses. Worth mentioning is the organization, 'AMAL,' which means 'action' in Pakistan's national language, Urdu. It has outreach HIV training programs focusing not only on IDU but also for the out-of-the-limelight population, female sex workers. On the other side, the current government policy falls under the auspices of the National HIV/AIDS Strategic Framework. The program has four foci: improved HIV prevention, expanding interventions among vulnerable groups, preventing transfusion related infections
and improving infrastructure. With over Rs. 2.9 billion (US $48 million) at its disposal, the program hopefully would chalk out a practical, concrete plan and then initiate work to implement it.
The Social Demographics
It may sound ludicrous but the fact remains that to properly combat any problem, the affected have to first accept it and then conquer over it. The society in Pakistan has as yet not accepted HIV/AIDS as having anything to do with them. Trends may be changing, but the age-old stigmas and taboos related to HIV still persist. HIV is considered extremely shameful, particularly in the rural setting. Even discussions on this topic are frowned upon. Awareness about HIV/AIDS in general is extremely limited. The severity of the situation could be deduced from a survey conducted among school teachers in the capital city, Islamabad. An outstanding sixty percent of the teachers responded by saying that 'they thought HIV was irrelevant in our cultural setting.' This awareness and acceptance issue would indeed be a big challenge, because 'teachers' as well as 'children' will need to be taught. UNAIDS latest figures estimate the number of cases in Pakistan bordering 85,000. Underreporting and limited surveillance means that the actual number of infected is much higher. Keeping in mind the poor healthcare facilities, the appallingly low literacy rate (in 2001, the illiteracy rate for Pakistani women over 15-year old was 72%), and a mushrooming population (growth rate of Pakistan lies at 2.5%), the stakes for a battle against HIV are indeed very low.
Challenges Faced By H.I.V/AIDS Patients And Reasons For Spreading Of AIDS/H.I.V
In this research paper, I want to explore the reasons for spreading HIV/AIDS and difficulties faced by HIV/AIDS patients in Pakistan. For this research I have reviewed the published and second hand literature to obtain the available data on HIV/AIDS in Pakistan. I have searched the electronic databases and read the books provided by LUMS Library. I picked this topic i.e. HIV/AIDS, because people feel reluctant in talking about such diseases and there is a social taboo 18
that patients of AIDS must have done illicit sexual discourse and are thus socially shunned by the relatives and friends. Also, this virus is a recently spread one in Pakistan and mostly people are unaware of this disease and feel fear in discussing sex related topics with families and life partners. In the end, I would tell that what are those difficulties and how those difficulties can be overcome and government and non-government organizations can provide an appropriate treatment to the Pakistani people.
Human Immunodeficiency Virus (HIV) is a virus which attacks on the immune system of the individual and makes it so weak that it cannot resist the weakest attack by any germ or bacteria and leads to the death of that individual. HIV can spread through the use of contaminated syringes, blades, improper screened blood transfusion, unprotected sex with male (MSW, HSW)or female and also from an infected mother to child and infected husband to the wife. (Altaf, Abbas, Zaheer; 2008). HIV/AIDS in Pakistan carries a negative connotation and people think that AIDS can only be spread through illegal sex and thus are reluctant in discussing sexual health issues in open because of the social taboo. Being a Muslim country, people in Pakistan consider sex a big fault in religious terms, HIV is mostly considered in Pakistan caused through illicit sexual discourse which makes people reluctant to share their views and even patients from seeking the treatment. This helped the virus in spreading more easily through the community and effected many people in Pakistan.
Pakistan and its people is the subject of my research. Pakistan is situated in South Asia, towards its east is India, in north is China, in north-west is Afghanistan and in west is Iran. Pakistan is a developing country and is struggling for its welfare and a place in the list of developed countries. A large portion of Pakistani population is still unaware of HIV/AIDS, especially in rural areas. Religious, social and cultural factors impact on HIV/AIDS patients, in acquiring a quality treatment and their survival in such a conservative society like Pakistan. These factors also play a vital role in spreading this disease and not letting people get the appropriate treatment and also keeping them unaware of the precautionary measurements like safe sex, using of sterilized blades and syringes. Pakistan has recently found this virus in its Injection Drug Users (IDUs), according to the reports HIV first found in 2003 and its ratio increased to 31% in 2007, in Karachi (HIV/AIDS Surveillance Project; 2006-7). The issue of HIV/AIDS prevention in Pakistan is a complex problem and requires a multifaceted approach with particular attention to cultural norms. In order to revise harm reduction strategies for HIV
prevention in Pakistan, it is important to study the social dynamics and practices of the populations at risk. Philip son and Posner  note that human actors make rational choices aimed at maximizing the expected utility of the outcome. The subjective welfare of the actor and presence of uncertainty are two inherent components of expected utility maximization. When acquiring information is costly, an uninformed choice – one that underestimates or overestimates the risk to health of some contemplated action – may still be expected utility maximization. Therefore, when education and counseling services are not readily and cheaply available, or when accessing such services means that the user has to disclose risk behaviors and is afraid to do so, he/she has no course but to make uninformed decisions. Effective counseling and education have been shown to change sexual behavior and reduce the risk of HIV transmission even in high risk groups. The Pakistan National AIDS Program (NAP) was set up in 1987 by federal government, assisted by donor agencies, to coordinate HIV/AIDS surveillance and control activities (8, 12). The NAP has established HIV testing centers in the country and screened more than one million people (10 15). Despite these important contributions, the data regarding HIV/AIDS in Pakistan has not been utilized effectively to inform proactive health policy. While activities at the provincial level, particularly in the province of Sindh have been productive, the other provinces have not followed as rapidly (8). In 1995, the four provinces of Pakistan were encouraged to form their own AIDS control programs with support from federal government. However, political issues and disagreements over program components have resulted in disparate success in the provinces. However a decade has passed since the recognition of HIV in country, groups at higher risk have been identified but still there are certain challenges and hurdles which are creating difficulty for the government as well as non-government organizations to offer a proper treatment and awareness regarding HIV/AIDS in Pakistan and also playing a significant role in spreading the disease across the community. These hurdles are education, economic conditions, misconception or low information regarding AIDS, gender inequality, stigma and discrimination. In the Muslim World, religion defines culture and the culture gives meaning to every aspect of an individual's life. Being a Muslim country, Pakistan has also a culture defined by Islam and has influenced each and every aspect of individual’s life. Following are the reasons for spreading of HIV/AIDS and are challenges and hurdles came across the appropriate treatment provided by governmental and non-governmental organizations in Pakistan, which need particular attention when designing HIV prevention programs for Pakistan:
1: Gender Inequality:
In Pakistani society, there is imbalanced power between men and women, which is apparent in heterosexual relations as well as in the economic and social spheres of life – with men having greater power than women. For most women, the private life within the sanctuary of their houses is their whole life. Due to such cultural settings of Pakistan, women remain uneducated and deprived of resources, unaware of their civil, legal and sexual rights, economically dependent on men. Due to these inequalities, women are more susceptible to contracting HIV/AIDS as they are less likely to be able to negotiate with their partners infected with HIV/AIDS. Women also are easy targets for abusive relationships and are less able to cope with illness once infected.
2: Stigma and Discrimination:
The social stigma attached to HIV/AIDS that exists in all societies is much more pronounced in Muslim cultures due to the religious doctrine regarding illicit sex and drug related practices. There are greater negative sanctions for sexual conduct than drug use. Even if there is a suspicion of illicit sexual conduct, the affected person(s) is discriminated against and shunned by the family as well as by the community. This stigma and discrimination attached to HIV/AIDS, discourages people from coming forward for appropriate counseling, testing and treatment, as this would involve disclosure of their risky practices. This results in creating barriers to successful implementation of prevention and treatment strategies where they do exist.
In developed countries, a majority of the population is aware of the modes of transmission for HIV infection, whereas in the developing countries, misconceptions about the disease and its causes are prevalent. Most of the Pakistani population consider that all HIV infections are transmitted only through immoral sexual behaviors and are unaware that it can also be transmitted frequently through mother-to-child, accidental pricking of skin and contact with contaminated blood (as in the case of health care professionals) or the possibility of an innocent spouse getting infected by the husband who may have acquired HIV though sexual or drug related contact with other infected persons. Therefore, due to lack of information and misconception regarding HIV/AIDS, lead to acquiring and spreading the infection and also deprive people from getting an appropriate care and treatment.
4: Poverty and Economic Condition:
About one third of the total population of Pakistan live below the poverty line and economic conditions of Pakistani population are getting worsen day by day because of low job opportunity and low business markets of Pakistan. Poor people in Pakistan cannot afford
the costly treatment or diagnosis of the disease. People living in rural areas do not even afford the traveling cost to urban cities in search of appropriate treatment. Poverty and poor economic condition of Pakistani population create difficulty for them to acquire a quality treatment for the HIV/AIDS.
5: Internal Conflicts:
Now a day Pakistan is facing many internal conflicts like Taliban, suicide bombing and Shia-Sunni conflict in Chitral (Emma Varley’s article). In conflicted zone, medical facilities get affected in many ways; difficulty in mobility or reaching in hospitals, availability of doctors, peaceful place to carry out the treatment, limited supply of medical equipment and medicines. Hospitals and doctors both get affected from such conflicts and senior or experienced doctors do not go into such conflicted areas.
6: Social Taboo:
Due to the social taboo in Pakistan, people feel shame or fear while talking about topics relating to sexual health in Pakistan. Also marriage partners cannot share their experiences regarding such diseases and women due to patriarchal society cannot go herself to seek the treatment because she is dependent upon her husband and her husband in return also don’t step forward to take care of her due to the social taboo that men never poke their nose in female health problem.
7: Other Issues:
In addition to the issues outlined above, the main challenges to instituting an HIV prevention approach include, wars, refugees, migrant labor forces, intimidating role of religious leaders and activists, and lack of healthcare resources and infrastructure. Social, religious and cultural barriers in Pakistan are the major hurdles for Pakistani people to acquire an appropriate diagnosis and treatment for HIV/AIDS. While a cautious approach will be suitable initially, giving proper information regarding the symptoms and adding some basic information in the educational syllabus of early education and social awareness regarding the symptoms, precautions and treatment of HIV/AIDS.
Alternative hypothesis: Rapid increase in HIV cases due to Homosexuality Null hypothesis:
Rapid increase in HIV cases not due to Homosexuality Other Variables: Usage of drugs Migrants of other countries Extra Marital Affairs Usage of Syringes and Tubes
NAME: __________________________ Gender: _________________________ 1) Please mention your age below bucket 16-20 21-25 26-30 31-35 2) Monthly Income 10000-15000 16000-20000 21000-25000 3) What do you think, which age of people faced HIV/AIDS disease? Youngers Adults 23
Mature 4) What would be the causes of HIV/AIDS?? Homosexuality Migrants of other countries Extra Marital Affairs Usage of Drugs Usage of Syringes and Tubes
5) What would HIV/AIDS positive do when he/she knows about disease? They should share with his/her partner He/she should share with Doctors He/she should leave home 6) What is your opinion for HIV/AIDS patients? ______________________________________________________________________ ____________________________________________________________________ 7) In your view what two factors are causing of HIV/AIDS? ______________________________________________________________________ ____________________________________________________________________
GRAPHICAL PRESENTATIONS OF FINDINGS 1)
30% 25% 20% 15% 10% 5% 0% 1 0 6-2 2 5 1-2 2 0 6-3 3 5 1-3
40% 35% 30% 25% 20% 15% 10% 5% 0% 10000-15 000 16000-20 000 21000-25 000
60% 50% 40% 30% 20% 10% 0% Young ers Adults Ma ture
0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 H os uality om ex Mig rants of Other countries Ex Marital Affairs tra Us e of D s ag rug Us e of S ag yring and es Tubes
0 .7 0 .6 0 .5 0 .4 0 .3 0 .2 0 .1 0 H e/she should with his/her pa rtners H he shouldshare e/S withD octors H e/she should lea ve hom e
The World Bank is the largest financer of HIV/AIDS programs in Pakistan. It assisted the government’s HIV/AIDS efforts Through funding the second Social Action Program (1998-2003). In addition, the World Bank is working with the government And other development partners (CIDA, DFID, USAID, UN Agencies) to support the government’s program through the HIV/ AIDS Prevention Project. The Bank is providing US$37.1 million, 75 percent of which is a no-interest credit and 25 percent of Which is grant money? This project is helping to scale up existing activities, ensuring that the program focuses on interventions That will do the most to interrupt transmission of HIV and make sure that interventions take full advantage of international Experience to date. The implementation of the enhanced program is making encouraging progress with Expansion of coverage of intravenous drugs users program in Punjab; awarding Service delivery contracts for sex workers and jail inmates in Sindh and Punjab; and Commencement of development of second-generation surveillance system. Significant implementation challenges remain, including addressing basic administrative
And financial management; slow progress in awarding next phase of service delivery Contracts and building capacity at provincial level. An important emerging concern is The limited in-country capacity for scaling up interventions for high risk populations And the urgent need for technical assistance to contracted NGOs, particularly for Programs with MSMs and sex workers.
Through internet, survey, books and help of expertise I have collected all stuff and complete my report.