The number of patients suffering from the lethal combination of tuberculosis and HIV/AIDS in Pakistan is increasing. A majority of those affected are marginalised communities such as sex workers and injecting drug users who have limited access to prevention and treatment, reports Aroosa Masroor

Tito, a transvestite sex worker is living with HIV-TB co-infection for four years. Three years after his HIV diagnosis, he contracted tuberculosis (TB). "We hijras (transvestites) are still not accepted by society. We either earn a living through begging or commercial sex, but once we are diagnosed with HIV and our clients find out, we have no business and hence no way to earn," he says, lighting his cigarette which he knows is harmful for his health.

"I know I will die soon and since I don't offer my services as a sex worker any more, I might as well make the best out of the time I have left."

Tito's story is not unique. He is one of the 2,150 people living with HIV registered with the Sindh AIDS Control Programme (SACP) and receives anti-retrovirals (ARV) through private hospitals and clinics working in collaboration with the government. According to official statistics, the total number of reported HIV cases in Pakistan is 4,502. It is estimated that about 90,000 cases remain unreported, a majority of them being injecting drug users (IDUs) and sex workers. After IDUs, sex workers are reportedly at the highest risk of contracting HIV.

As in other parts of South Asia, the disease is fast spreading among sex workers in Pakistan causing concern among health experts. However, it is the private clinics that are providing the required drugs and treatment in the red light districts because sex workers are hesitant to visit government hospitals.

"We feel harassed at government hospitals," says Kiran, a female sex worker in Lyari, a poor area of Karachi.

Providing treatment is not the only problem; the attitude of clients also plays a strong role in spreading the virus. NGOs like the New Light AIDS Control Society, Bridge Consultants Foundation, and Infection Control Society of Pakistan (ICSP) have been raising awareness about contraception among sex workers, but it is not enough.

"It's our clients who need counselling. Resisting them and compelling them to use condoms is very difficult," adds Kiran.

Tuberculosis-HIV co-infection

The increasing prevalence of HIV among male, female and transvestite sex workers in Pakistan has given rise to another fear among health experts who say the high prevalence rates among these groups may lead to an increase in tuberculosis-HIV co-infection.

Although the precise number of patients suffering from the lethal combination is unknown, doctors say the number is increasing gradually. "Because HIV weakens the immune system, people with HIV are more likely to become infected with tuberculosis (TB) and, similarly, every TB patient is vulnerable to HIV as well," explains Dr Sharaf Ali Shah, executive director, Bridge Consultants Foundation. "It has been proven that the presence of mycobacterium tuberculosis and biological changes in the patient's body are likely to accelerate progression of the HIV disease," he adds.

Although HIV-related tuberculosis is both treatable and preventable, the incidence rate continues to rise due to limited resources and medicines. "The government is providing us the antiretroviral drugs for free, but that's not all we need," says Brother Khushi of New Light AIDS Control Society. "We need other drugs too for complete treatment of the disease but we do not have the money to buy them. That's why it is difficult to cure the disease."

Sex workers worse off

The situation among sex workers, male, female and transvestite, is even worse because they are socially marginalised. "When infected, they prefer visiting their neighbourhood clinic or NGO for treatment," says Wajid Ali, field administrator of the ICSP. He says most female sex workers refrain from unsafe sex.

Transvestite sex workers, however, have much less control over decisions pertaining to commercial sex. Though most transvestites in Lyari -- a crime-infested low-income suburb of Karachi -- show a high level of awareness about the disease and its prevention through condom use, they say resisting clients is not easy.

Wajid Ali adds that through its Tahafuz-e-Sehat programme, the ICSP has managed to educate a large number of male sex workers too, most of whom live in denial especially because their families are unaware of their sexual orientation.

Male sex workers

According to the HIV and AIDS Surveillance Pakistan Report 2006-07, an estimated 19,320 male sex workers offer their services in the 12 main cities of Pakistan -- Lahore, Multan, Sargodha, Karachi, Banu, Quetta, Peshawar, Larkana, Sukkur, Hyderabad, Faisalabad and Gujranwala. But NGO statistics reveal that over 14,000 male sex workers live in Karachi alone. Most of them belong to the Pukhtoon community.

"An increasing trend of male sex work is being reported among the Pukhtoon community who are away from their families after migrating from rural to urban parts of the province in search of better jobs," adds Wajid Ali. "The percentage is higher than ever before and they report low rates of condom use hence increasing the risk of exposure to HIV."

NGOs point to another major problem. Since medical facilities at government hospitals are inadequate in rural Pakistan, most persons with AIDS are registered with private clinics. However, the official death toll does not record these patients as having died of AIDS.

For a person who is co-infected, dual registration is even more difficult. "It is not fair that a patient suffering from both HIV and TB be asked to register separately," says Dr Saleem Azam of the NGO Pakistan Society. "Considering the commuting fare from one diagnostic centre to the other and the limited financial resources available, coupled with the stigma that the patient is undergoing at the time, it is unfair to expect the patient to complete all the formalities."

Dr Ghulam Abbas, medical officer and zonal TB coordinator of Sindh TB Control Programme, offers a slightly different view. "Treating HIV-TB co-infection would complicate treatment and care for both diseases,” he says.

Meanwhile, Dr Azam does not underestimate the significance of the linkage between the two diseases. He adds that concrete measures need to be adopted to contain the possible spread of HIV and AIDS, and TB before they result in a deadly co-epidemic, as is already happening in other parts of the developing world.

For Tito, it is perhaps too late. He awaits his death instead of being an added burden on the community. "With the increasing rate of inflation, our hijra community can barely afford two square meals a day. I don't expect them to pay for my medicine when I am not contributing financially. It's better for me to die."

Panos 2010 Features

(Aroosa Masroor Khan works as a correspondent for the local desk at The News International in Karachi)

InfoChange News & Features, November 2008