Hiv control in pakistan hampered by social taboos

Hiv control in pakistan hampered by social taboos

In Pakistan, controlling the HIV epidemic is made even more challenging due to social taboos related to men who have sex with men (MSM), according to a Personal View released in The Lancet Infectious Diseases on July 22, 2008.

Dr Syed Ali, Aga Khan University, Karachi, Pakistan, and colleagues first point out the disparities in statistics regarding HIV infection in men and women in Pakistan. "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 According to unpublished reports, the prevalence of HIV among homosexual and bisexual Pakistani men is reaching alarming proportions," they say.

According to the laws is Islam, any kind of sex other than that between a husband and wife is haram or forbidden. As a result, homosexuality is socially and legally unacceptable, and can lead to stigmatization, discrimination, ostracism, and in extreme cases prosecution. Given this, 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 continue with the problem of safe sex promotion: in a Muslim state, this is tantamount to promoting sex, making even this subject taboo.

The authors indicate that this results in societal denial about the prevalence of homosexuality, especially as a risk factor for HIV infection. "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."

There are several MSM subpopulations described by the authors. These include: hijras, or enuchs, are biologically male but identify as females; zenanas, who believe they are women trapped in men's bodies, and thus often are married, leading to clandestine extramarital relations; chavas, who may change sexual roles; giyras, who are married to zenanas or hijras, and may be unaware of the promiscuity of their spouses; maalishias, who are boys employed as masseuses who sometimes sell sex. Additional at risk groups include male sex workers and injection drug users (IDUs), prisoners, migrants, truck drivers, and pederasts/pedophiles. And preexisting sexually transmitted diseases increase the risk of HIV infection by many times.

Many challenges are faced in encouraging safer sex in the face of this environment. Male sex workers often service between three and five customers each night, charging $0.80 to $1.60 US dollars (50 to 100 rupees) per client, and provide services in private homes, on the street, or in public meeting places. Introducing condoms is a challenge, as clients can often simply find another prostitute who will assent to unsafe sex. Preventing this further, a serious stigma is associated with condoms in any setting. They cannot be displayed in shops, discussed, or used in media campaigns due to disapproval by the public.

Education regarding HIV/AIDS in men with sexually transmitted infections in Pakistan is also inadequate. According to the authors, only 28.3% of those surveyed understood that HIV could be transmitted to a partner, and only 16.7% are aware that prevention lies in safe sex practices. In an additional challenge, many men who buy or sell sex do not consider anal sex to be a true form of "sex." As a result, they believe that safe sex measures will not apply to this act.

In light of similar influences, the writers note that more candid discussions have occurred even in conservative countries like India and Bangladesh. They say that this has not moved forward in Pakistan, where "sociocultural and religious taboos hamper recognition of HIV/AIDS as a sexually transmitted disease and limit discussion on sexual health."

The Pakistani government has made some motion in these directions. According to the authors, an expanded HIV/AIDS program has been established to prevent HIV from presenting in vulnerable populations and further spreading to the general population, while attempting to prevent stigmatization of these vulnerable groups. While the authors believe this is commendable, they say that the outreach programs must cater to the special characteristics of the MSM subpopulation in order to be effective.

They provide several suggestions for future legislation in this area. For one, any pamphlets or educational materials that discuss safe sex must define the term carefully, and include anal sex in this definition. Additionally, they believe that young boys who are sexual victims of elderly men should be protected legally.  The stigma associated with condoms must also be seriously addressed. Finally, the authors conclude that the integration of HIV policy into the constitution must occur, including provisions for the possession of condoms.

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."

HIV and homosexuality in Pakistan

Alefiyah Rajabali, Saeed Khan, Haider J Warraich, Mohammad R Khanani, Syed H Ali

Lancet Infect Dis 2008; 8: 511-15

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