News Release

Social taboos make controlling HIV epidemic in Pakistani men who have sex with men very challenging

Peer-Reviewed Publication

The Lancet_DELETED

Social taboos in Pakistan make the controlling the HIV epidemic in men who have sex with men (MSM) very difficult. Outreach programmes must reach subpopulations in MSM, and there are commendable signs that the Pakistan government is now recognising MSM as a population especially vulnerable to HIV infection. The issues are discussed in Personal View paper in the August edition of The Lancet Infectious Diseases, a special edition devoted to HIV which will be at the world HIV conference in Mexico 3-8 August.

Authors Dr Syed Ali, Aga Khan University, Karachi, Pakistan, and colleagues say: "In Pakistan, seven times more men are reported to be infected with HIV than women….Although most sexual transmission of HIV results from unsafe heterosexual contact, homosexual and bisexual contact also represent important modes of transmission. According to unpublished reports, the prevalence of HIV among homosexual and bisexual Pakistani men is reaching alarming proportions."

Under the tenets of Islam, sex of any kind, other that between husband and wife is haram — meaning strictly forbidden. As it is legally and socially unacceptable, homosexual behaviour can lead to stigmatisation, discrimination, and ostracisation from family and friends, and even prosecution. The authors say: "Most Pakistanis tend to believe that HIV transmission through illicit sexual activity cannot be a problem in the Muslim world. The statistics, showing that HIV transmission through sexual activity is gradually rising, contradict this popular notion."

Given that all extramarital sex is forbidden by Islam, the authors say: "One would suppose that the fear of God in itself would be enough to discourage illicit sex among men who have sex with men. Unfortunately, the moral approach only serves to drive the behaviour underground." They add that in a Muslim state, promoting safe sex is the equivalent of promoting sex, making tackling the MSM HIV epidemic even more difficult.

Several subpopulations within MSM are at particular risk of HIV infection. Hijras, identified as eunuchs, are biologically male but identify themselves as female and are receptive partners in anal sex. Zenanas beliveve they are women trapped in men's bodies, and chavas also identify with the female gender. Giryas are men that marry hijras and zenanas, who may be unaware of their spouse's promiscuity, putting them at risk. Maalishias are boys who are masseurs by profession, but who may also sell sex. Male sex workers and injection drug users (IDUs) are also at risk – with 27% of IDUs in Karachi known to be HIV positive. Prisoners, migrants, truck drivers, and pederasts/paedophiles are also at risk — in certain parts of Pakistan it is tradtional for elderly men to take young boys as sexual partners.

Male sex workers can service three to five customers a night, charging as little as 50-100 rupees (US$0.8-1.6) per client, with service provided in private homes, the street or public meeting places. Using condoms is difficult when clients can simply find another prostitute who will agree to unsafe sex. Pre-existing STIs also increase the risk of getting HIV four-fold. Knowledge of HIV/AIDS in men with sexually transmitted infections in Pakistanis is poor, with only 28.3% realising they can transmit HIV to their partner and only 16.7% aware that prevention lies in safe sex.

The authors acknowledge that even relatively conservative countries such as India and Bangladesh have begun to address the HIV prevention more openly. They say: "In Pakistan, however, sociocultural and religious taboos hamper recognition of HIV/AIDS as a sexually transmitted disease and limit discussion on sexual health." Tackling the epidemic will mean taking on many challenges, including things as basic as the fact that many men who buy or sell sex don't consider anal sex to be a form of sex, and thus believe safe sex measures don't apply to anal sex. Any pamphlets etc, that tackle safe sex must address this and actually define sex. The young boys who are sexual victims of elderly men must be given legal protection. And, perhaps the most serious issue is the stigma associated with condoms — due to social disapproval condoms cannot be mentioned or displayed in shops or used in electronic or print media campaigns.

Despite these challenges, the Pakistani government has formed an expanded HIV/AIDS programme, which aims to stop HIV becoming established in vulnerable populations and spreading to the general population, while avoiding stigmatisation of these vulnerable populations. The authors say this is commendable, but outreach programmes must target the special characteristics of subpopulations of MSM to be effective. They conclude that the greater national challenge appears to be integration of HIV policy in the constitution, with the issues around carrying condoms a thorny matter. Legal restrictions are being relaxed for IDUs — the distribution of free disposable syringes is now allowable among them — and societal changes need to be extended to promote safe sex in the MSM population. The authors conclude: "As insurmountable as the challenge may seem, this will only occur when advocacy is used to sensitise policy maker, politicians, and religious figures in the country."

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Dr Syed Ali, Aga Khan University, Karachi, Pakistan T) +92 21 493 0051 ext 4433/4431 E) syed.ali@aku.edu


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