Ahsan Butt

Breaking the silence on AIDS in Pakistan

To gauge the general population's awareness about AIDS, I went to Karachi's Park Towers, an area where one can find people from all sections of society. One can find Aunties inside the building who use the word "darling" while outside one finds young and middle aged men using the same word, if not in the same context. Inside, shoppers like 37 year-old Syed Mehdi, 32 year-old Tasleem, 19 year-old Sirosh and 24 year-old Huma all showed a basic understanding of AIDS and how it is contracted. I asked a group of 12 year-old girls what they knew about AIDS and was greeted with giggles. They were too embarrassed to use the "s" word but said something about cuts and bleeding. I smiled and moved on.

The story on the street was, however, very different. One woman turned away and didn't look back at me as soon as I mentioned the word AIDS. Posing the question of how AIDS is contracted to others, I was met with uncomfortable shifting and evasive comments. Usman, a driver, got up and left with only the hackneyed "We shouldn't talk about these things in public." Some, however, were willing to talk. Forty-five year-old Mohammad Siddique said, "Ghalat harkatein karein gey to beymaar hoen gey (if one indulges in wrong activities then one will fall sick)." Abdur Raheem, 33, said, "It's best to stay away from the "bad" people.

Even if you use condoms, there's only an 80 per cent chance that you will be saved." What was clear from talking to these people was that they by and large weren't aware that one could get infected with AIDS without having sex, that is, they didn't know that needles and syringes were just as dangerous as intercourse.

For those that don't know, here are the bees and butterflies of HIV/ AIDS: One can get infected with the Human Immunodeficiency Virus (HIV) by having unprotected sex with a partner already infected; by having one's blood come in to contact with HIV infected blood from needles, syringes and piercing guns, and HIV infected mothers can pass the virus on to their unborn babies during pregnancy. One cannot get HIV from kissing, hugging, drinking water from the same glass or working in the same office as someone infected with HIV. The common denominator is infected bodily fluids (blood, semen and vaginal fluids) coming into contact with one's own. The virus breaks down the body's immune system (thus the name of the virus) which, in turn, is less likely to fight common infections and diseases like the flu, which suddenly become lethal.

AIDS is the last stage of HIV. If the HIV virus is spotted at an early enough stage, medication can be taken which can help control it, although there is no guarantee that the HIV infected person will not get AIDS, even with medication. If you get HIV, you won't necessarily die but there's a good chance that you will. If you get AIDS you will die because of it. End of story. The only way to save oneself from HIV/AIDS is prevention: using condoms when having sex, using previously unused syringes for vaccinations and drug use, covering cuts with bandages as soon as possible, especially if playing sports, using your own blades when shaving and using your own toothbrush if you have bleeding gums. If you are getting tattooed or pierced, make sure it's done at a reputable place.

AIDS in Pakistan has remained relatively dormant over the last 15 years, a period in which AIDS has exploded in other parts of the world, particularly sub-Saharan Africa. Besides the 25 million deaths AIDS has already caused, the number of people living with HIV has risen to above 40 million. Over 10,000 people become infected with the virus every day. Despite the statistics that point to the disease pervading every part of the world, Pakistan hasn't been affected as badly as other regions: today there are an estimated 70,000-80,000 Pakistanis infected with the HIV virus.

While Pakistan has hitherto been relatively unscathed from AIDS, experts say that could change quickly. "We are still in the low prevalence stage," says Dr. Syed Abdul Majeed, assistant professor at Karachi's Jinnah hospital (see box). "We are, however, approaching the second stage, the concentrated epidemic stage, that is when the high-risk sub-populations (prostitutes, IV-drug users, truck drivers) are widely infected. Fortunately, we're far off from the last stage, the generalised epidemic stage, when 5 per cent of the general population has the virus. Still, we have to be very careful." Very careful, indeed: the region is fast becoming a hotbed for the virus; India has more people living with AIDS than any other country in the world except South Africa. There are various signs abound that the virus could proliferate alarmingly in Pakistan if not checked.

Studies show that injecting drug users are usually the first community in Asian countries to be infected with the virus. There are an estimated 500,000 people in Pakistan who inject heroin. With the fall of the Taliban government in Afghanistan, heroin use in Pakistan has risen and is expect to continue to rise. Because heroin users generally share needles, they are quite naturally at a high risk. Experts say, however, that heroin users in Pakistan aren't a serious threat to spread the virus to other sections of society. "Those who get AIDS from needles injecting heroin don't pose as great a risk as say, truck drivers or prostitutes simply because, unlike in the west, drug users on the street in Pakistan aren't significantly sexually active. The result is that the heroin user who has HIV will typically transfer it to other drug addicts from needles rather than others through unprotected sex. In other words, a heroin addict can only spread the virus as far as other heroin addicts," opines an analyst.

Migrant workers and refugees are one of the main tributaries of the virus. A significant number of Pakistanis work abroad, especially in the Middle East, and many serve in international armed forces. These groups are especially vulnerable to HIV, and pose a great threat when they come back home, putting their spouses, sexual partners and contacts at a greater risk. Studies indicate that the truck drivers of Pakistan who operate on routes throughout the country, are at major risk as they are known to be sexually active, as both homosexuals and heterosexuals, and usually have multiple partners.

A study in 1996 found that only 44 per cent of Karachi's sex workers believed that HIV was sexually transmitted. This ignorance, coupled with the fact that sex workers are seldom in a position to enforce the use of a condom, only serves to spread the deadly virus. The ignorance in question is especially hard to deal with in a society like Pakistan's where any talk of sex is taboo, and combined with low literacy rates, makes the task of spreading awareness among Pakistan's population that much harder. Ignorance in Pakistan is not limited to the illiterate — one study showed that 35 per cent of hospital doctors were not aware that HIV could be transmitted from mother to child.

Finally, the safety of medical practices, or lack thereof, is a major issue. A World Bank study estimated that 40 per cent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. In 1998, the AIDS Surveillance Center in Karachi found that one per cent of professional blood donors were infected with HIV. Studies indicate that 94 per cent of injections are administered using already used injection equipment, and according to World Health Organization estimates, up to three per cent of new HIV cases in Pakistan are due to unsafe injections. Says Moinuddin Ahmed, an assistant at the AIDS Surveillance Center at the Jinnah Hospital, "I know of places where syringes and needles are used and then sold in the market for reuse. What's the point of educating the common man if doctors and nurses care, or know, so little?" He adds that malpractice is a bigger problem in rural Pakistan. "We have many doctors who obtain fake degrees and are practicing medicine in villages. They don't know what they're doing and, unfortunately, neither do the patients."

So what has been, and is being, done about AIDS in Pakistan? Domestically, government action started as far back as 1987 — when a Federal Committee on AIDS was set up. The Ministry of Health also set up a National AIDS Prevention and Control Program (NACP) that same year. The NACP has played an important role, creating awareness through publication of educational materials, electronic media campaigns and organizing workshops and informational meetings. In 1995 Provincial Implementation Units were set up in all four provinces as well as Azad Jammu and Kashmir in an effort to strengthen coordination between federal and provincial governments in their response to the threat of AIDS. In 1999 the NACP, with support from UNAIDS, initiated a strategic planning process, hiring a team of experts to investigate the AIDS situation in the country. These experts brought out a document, HIV/AIDS in Pakistan: A Situation and Response Analysis, which was to be the basis for subsequent planning and discussion. In 2001 the government developed a national HIV/AIDS Strategic Framework that set out the government's priorities for course of action and potential barriers.

Aside from government efforts, UNAIDS has established a Theme Group and Technical Working Group on HIV/AIDS to coordinate the response of the various UN agencies (UNICEF, World Bank, WHO, UNESCO etc) and to provide assistance to the government. Along with this, there are at present close to 100 NGOs in Pakistan which are involved in AIDS programs, working on education and prevention, targeting sex workers, truck drivers and other high risk groups. They serve as members of all four Provincial HIV/AIDS Councils. However, it is estimated that NGOs reach less than five per cent of the vulnerable sections of society and are not as active as they could be. "The sad reality is that there's a lot of talk but when it comes down to it, very few NGOs are actually doing work on the ground," says a senior NGO representative.

How successful have the collective efforts of the Pakistan government, UN agencies and NGOs been? Analysts aren't sure. "Most people are aware of the dangers of unprotected sex, but they lack the knowledge of the dangers of needles," says one such expert.

"The average Pakistani rarely ever goes a hospital or clinic. If a doctor or nurse gives someone an injection, they are not going to ask questions about the safety of the procedure," he adds. Indeed, it seems that those who should be the most aware of the dangers of using used needles — the paramedics — are missing the lessons of the various public service announcements regarding sterilizing needles and syringes.

However, experts say that such public service announcements can not be categorized as futile. "In the last three years PTV has starting showing these announcements more regularly and given them prime time spots. In addition, these announcements are a lot more explicit than what they used to be when they starting airing in the early '90s," says an analyst. That is the reason, he explains, that people know more about the dangers of multiple sex partners and the use of condoms. "The advertisements have also helped in convincing people to go and get tested for HIV," he adds. Backing that claim is Dr. Syed Syed Sharaf Ali Shah, project director of the Government of Sindh AIDS Control Program. "Last year some 12,000 people got tested for HIV, compared with only 2000-3000 in years before that," he says. (See box.) "It's the little things that matter," says another analyst. "Lately, in cities like Karachi and Lahore even the roadside barbers, the nayees, have started changing blades before shaving customers, whereas before this was something done only in posh men's salons."

The social and religious nuances of Pakistani society have provided an almost oxymoronic aspect to the fight against AIDS. "The cultural values in Pakistan have generally managed to keep a lid on widespread sex with different partners," says an expert. "However, the reluctance to talk about sex and the use of condoms could be a major reason for a potential explosion of the AIDS epidemic in the country," he warns. Denial is also a major issue. "The average person doesn't think that they can also get AIDS. People believe that it can't happen to them, that it can't be an issue in a Muslim country," says an analyst. "Senegal… is a Muslim country," says Dr. Majeed. "They targeted areas to work on and are today one of the few low-prevalence countries in Africa."

Shazia Premjee of Aahung, an NGO that works on sexual diseases and other health issues, shed some light on how to counter the conservatism that could end up facilitating the spread of HIV. "When we go in to villages and rural areas, we don't treat AIDS as a separate entity. We talk about the human body as a whole and reproductive organs in particular. People are of course shy, but it helps if we approach it from a health angle, rather than pass moral judgement," she said.

She isn't alone in employing that strategy. John Hetherington, Executive Director of Social Marketing Pakistan (SMP) says, "We take a holistic approach to HIV. We talk about health issues in general, and people are more forthcoming about sexual activity than one would think. The people in high-risk groups are all in the same boat, so if you talk to them and tell the truth, they're willing to listen and talk, because ultimately, it's their health that we're talking about." SMP also control about 80 per cent of the condom market in Pakistan, and give condoms to various NGOs on credit. "Our primary goal with the condoms is family planning, that goes without saying," says Hetherington, "but it's important that people are now understanding that condoms can prevent disease as well." Premjee adds that the independent media should bear the burden of spreading awareness as well. "The media in Pakistan is very conservative when it comes to these things. When they don't talk about things which are considered taboo for fear of retribution from conservative circles, they are simply practicing self-censorship which is unhealthy."

Just because AIDS hasn't struck Pakistan as badly as other countries doesn't mean that significant efforts shouldn't be undertaken to combat the virus. Experts unanimously agree that Pakistan is a vulnerable country and shouldn't be naïve about the threat of AIDS. "Four years ago, the Indian government estimated that there were 1000 cases of AIDS in their country. Now, those estimates are close to four million. If we don't do something, this is a large crisis waiting to happen," warns Hetherington.

So what else can be done? "We need structural adjustments, both at the policy level and at the implementation level," says Premjee. "People need to realize that AIDS isn't just a problem for drug users or sex workers. Everyone is at risk and therefore more people need to be involved; donations, government activity, media attention, everything," says Hetherington.

The best way to deal with problems on a national scale in general, and AIDS in particular, is to not let them become problems in the first place. The difficulty in dealing with such problems rises exponentially over time, that is, they are infinitely tougher to withstand against if not nipped in the bud. If Pakistan wants to avoid an AIDS problem comparable to that of Africa, it would do well to organize its own preemptive strike before it's too late.