Social taboos and a weak public health infrastructure have combined to prevent an effective response to the HIV epidemic in Pakistan. The epidemic is largely restricted to groups at high risk but it is feared that, in the absence of a comprehensive programme, it will move into the general population.

By Sandhya Srinivasan

HIV prevalence is much below one percent in the general Pakistani population. The government’s 2007 progress report to the UN General Assembly Special Session (UNGASS) on HIV and AIDS describes the country as having a concentrated epidemic among injecting drug users (IDUs) and men having sex with men (MSM); various small surveys have found HIV prevalence ranging from 2 - 14 percent among IDUs and up to 50 percent among transgendered people. An estimated 85,000 people in the 165 million population are living with HIV.

The report warns: “There is still a reluctance to accept that there is a danger of a generalised epidemic.”

There is a basic unwillingness to discuss HIV, though this has changed over the years, says Yasmeen Rehman, a member of Pakistan’s national assembly since 2002, and founder- chairperson of the country’s parliamentary forum on HIV and AIDS. “When we first raised HIV as an agenda item in parliament, men came to me and said, ‘You are a good woman, why are you talking about HIV?’.” Rehman, who is with the Pakistan People’s Party, is also on the standing committee for health.

“In 1999 I was told by my professor in medical college that AIDS was not a problem in Pakistan because it is a Muslim country,” says Donya Aziz, a medical doctor by training and member of the national assembly from the Pakistan Muslim League, also since 2002. Aziz and Rehman have put party affiliations aside to work together on health and HIV, and their consistent campaign has had an impact. “Today, we’re actually talking about HIV and other reproductive health issues,” says Aziz, who is deputy convenor of the committee on health and sustainable development.

While talking about HIV is not taboo as it was some years ago, “It is still difficult to speak in detail about certain things,” says Rehman. “Like about sex workers and MSM … people have misconceptions on how Islam views the subject. But there should be no confusion; Islam is clear about talking about sex. Childbirth is the subject of one of the suras of the Koran.”

Rehman also points out that the focus on sexual transmission distorts the discussion. “We really have to make it clear that HIV has different modes of transmission.” Pakistan has one of the highest rates of IDUs in the world, according to a 2009 research brief by the National AIDS Control Programme, Pakistan, the Sindh Institute of Urology and Transplantation and the London School of Hygiene and Tropical Medicine.

Reluctance to discuss sexual issues affects the quality of information as well. One of the major challenges to the HIV and AIDS programme, identified in the UNAIDS document, is that “cultural, social and religious taboos concerning the discussion of sexual behaviour have inhibited the public discussion of reproductive health and sexual behaviours.” Indeed, data on certain indicators, such as the frequency of multi-partner sex, are not available and apparently cannot be collected “due to socio-cultural reasons”. And, for example, MSM are not an identified population in Pakistan so data on MSM are limited to what can be gathered from male sex workers and transgender people.

There has, however, been much change in the last decade, according to Aziz.  “We are accepting that we can and do have HIV, and that it is something we need to talk about to prevent adequately… still major challenges remain.’’ The foremost of these challenges is the lack of funds for health, according to Rehman. “The recession has forced further cuts in the already underfunded health and education budgets. A major portion of the budget goes to debt servicing, then defence. Health and education take the lowest priority. When we ask the minister, he says there is a provincial budget, take it into account when you look at the health budget, but even that is not enough for the growing population. And what are the health facilities we are offering?”

A report by the Pakistan Institute of Development Economics says that per capita public expenditure on health is just four dollars compared to 34 dollars recommended by the World Health Organisation (WHO), the minimum to provide a very basic package of health services.  “Like… other social sectors health is not a priority area of the Pakistani government,” the authors write.

It is a fact that the rural poor, who make up 70 percent of the population, have little access to care. The majority must consult private doctors for healthcare. Primary health centres are non functional, says Rehman. “We do have rural basic health units, but the doctors do not want to go to rural places and perform their duties; instead, dispensers are giving medicines.” There is a shortage of doctors and a severe shortage of nurses.

“At the top of my wish list is to improve health facilities,” says Rehman. “We need to increase the number of testing centres. Lahore is a big city and has just four testing and care centres and most of them are open only for half of the day, rest of the day I am not sure the doctors are there.”

While priority is given to prevention, treatment is also an important part of any HIV and AIDS programme. However, just 7.5 percent of the Rs 1.85 billion (14 million US dollars) in the HIV and AIDS programme was spent on care and treatment in 2006-2007, notes the UNGASS report. Less than one percent was spent to address the need of orphans and vulnerable children about whom no data are available.

The UNGASS report also points out that “quality of care in counseling and treatment services remains an issue.” There are nine centres for AIDS care including anti-retroviral therapy (ART). Of an estimated 7,500 with advanced HIV illness (which needs ART), just 500 (7.4 percent) receive ART through the government programme.

“I think health is the biggest issue that faces Pakistan,” says Aziz, noting that 50 percent of the population is under the age of 20 and will start their reproductive lives without access to basic services. Women give birth to and rear children through until their 40s. “This contributes to a lot of maternal and infant morbidity.” 100 out of every 1,000 children that are born die before the age of five. More than 350 women (for every 100,000 children that are born) die during pregnancy or childbirth.

The lack of services for Pakistani youth is a major challenge according to the UNGASS report. Just six percent of the country’s schools provided some kind of life skills-based HIV education within the 2005-2006 academic year, according to available information.

Since her entry into the assembly, Aziz has been advocating for reproductive health and rights and information for adolescents. “We have a very young population. Because of the conservative nature of our society there is no healthy place for them to get information from. Simultaneously, the media sells sex no matter which country you’re in and there is an information overload, online messages are unhealthy, and young people don’t know what is happening with their bodies, where to get answers to their questions.” At the top of her wish list is “to have reproductive health included in the curriculum in secondary schools.”

“I would say that since 2003-2004, things have changed somewhat for people living with HIV,” adds Rehman. “We have moved legislation to check the spread of the virus by improving prevention programme, increasing the number of testing facilities as well as providing care and support for people living with HIV and AIDS, especially widows.”

Victims of violence are also at great risk of HIV infection, and the Domestic Violence (Prevention and Protection) Bill, introduced by Rehman, was viewed as a step in the right direction. In August 2009 the national assembly unanimously passed the bill that for the first time held domestic violence to be a crime. Women could apply to the court for an order of protection from violence and dispossession as well as for monetary relief. A breach of this order would be punishable with imprisonment and a fine to the aggrieved person.

This would have given a boost to HIV prevention efforts. However, the bill lapsed after the Senate failed to pass it within three months of passage in the national assembly, reportedly sabotaged by conservative sections.

Panos Talking Point, February 2010