HIV and homosexuality in Pakistan

doi:10.1016/S1473-3099(08)70183-X

The Lancet Infectious Diseases

Volume 8, Issue 8, August 2008, Pages 511-515

https://doi.org/10.1016/S1473-3099(08)70183-X Get rights and content

Summary

In Pakistan, seven times more men are reported to be infected with HIV than women. Among the Pakistani population, modes of HIV transmission include infection through sexual contact, contaminated blood and blood products, injecting drug use, and mother-to-child transmission. 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 According to unpublished reports, the prevalence of HIV among homosexual and bisexual Pakistani men is reaching alarming proportions. We describe the Pakistani homosexual and bisexual culture, review statistics regarding HIV prevalence and risk behaviour, and identify areas of improvement in the HIV policy with specific focus on men who have sex with men.

Introduction

The prevalence of HIV in men who have sex with men is important for several reasons. In 2006, more than 70% of HIV-positive people in south and southeast Asia were men.¹ In Pakistan, of the reported cases of those infected with HIV, men outnumbered women by seven times, and 7% of HIV-positive individuals were men who have sex with men.¹ Owing to high-risk behaviour, such as drug use and promiscuity, the risk of HIV transmission may be greater among the homosexual than the heterosexual population.2, 3, 4 It is therefore imperative that men who have sex with men are treated as a high-risk group for HIV and receive due attention when HIV awareness and control strategies are devised.

The first case of AIDS in Pakistan was reported in 1987, in Lahore.5, 6 Since then, the number of people infected with HIV has gradually increased.⁷ The official number of reported HIV cases in 2002 was 1913,8, 9 which had increased to 85 000 by 2005.¹ The most frequent modes of HIV transmission among the Pakistani population include infection through sexual contact, contaminated blood and blood products, injecting drug use, and mother-to-child transmission.1, 2 Although most sexual transmission of HIV is caused by unsafe heterosexual contact, homosexual and bisexual contact are also important.2, 3, 4, 7

We review the population of men who have sex with men in Pakistan. We describe the Pakistani homosexual and bisexual culture, review statistics regarding HIV prevalence and risk behaviour, and identify areas of improvement in the HIV policy with specific focus on men who have sex with men. The source material for this Personal View was accessed through PubMed and Google search engines. Because of the paucity of published data on the subject, we also accessed several unindexed journals and newsletters, such as those of the Pakistan Infection Control Society, Pakistan AIDS Prevention Society, and Naz Foundation International. Reports from the Pakistan National AIDS Control Programme and UNAIDS were consulted for current HIV/AIDS statistics. Additionally, we visited some homosexual communities in Karachi, Pakistan, and interviewed men who have sex with men to gain insight into the structure of Pakistani homosexual and bisexual culture and to identify specific behavioural patterns and issues associated therewith.

Section snippets

Pakistani men who have sex with men: a social perspective

Pakistan is an Islamic republic, where culture, society, and law integrate religion in all codes and values that determine everyday life. Sex outside marriage, including homosexual sex, is taboo in Pakistan;¹⁰ under the tenets of Islam, sex of any kind, other than that between husband and wife is haram (strictly forbidden). Because it is legally and socially censured, overt homosexual behaviour in this country can lead to social stigmatisation, class discrimination, ostracisation from family

Men who have sex with men demography in Pakistan

In Pakistan, male to male sex appears to exist among seafarers, prisoners, drug users, truck drivers, migrant men, male prostitutes, and married men who have extramarital sex contacts.13, 14, 15, 16, 17 Within the broad definition of men who have sex with men, hijras (transvestites), zenanas (she-males), maalishias (masseurs), and chavas (men who have sex with men who switch sexual roles) represent subsets of men who have sex with men that have a substantial risk of HIV infection.8, 18

High-risk behaviour in men who have sex with men

The social classes of men who have sex with men described above are often involved with selling sex, and are normally promiscuous in their sexual behaviour. On average, a male sex worker will service three to five customers per night. Identified meeting places for sex partners include the street (49%), private homes (21%), and public spaces (24%).⁸ In the urban areas, there is also a network among hijras and zenanas that helps them communicate with and cater to their clients in private houses (

Controlling HIV/AIDS in Pakistani men who have sex with men

The political setup and social dynamics in Pakistan present unique challenges to the implementation of a proactive and organised AIDS prevention programme. The relatively conservative south Asian countries of India and Bangladesh have begun to address the issue more openly.30, 31, 32 In Pakistan, however, sociocultural and religious taboos hamper recognition of HIV/AIDS as a sexually transmitted disease and limit discussion on sexual health.¹⁰ Although Islamic strictures and traditional social

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Citation Excerpt :
Coverage of sterile syringes for intervention cities reached 30% compared to only 13% nationwide in 2007 (Khan & Khan, 2011). There is also an emerging epidemic among the Hijra (Rajabali, Khan, Warraich, Khanani, & Ali, 2008). HIV prevalence among HSW has significantly increased between national surveillance rounds, rising from 0.82% (95% CI 0.4–1.3) in 2005 to 6.35% (95% CI 5.0–7.7) in 2008 (NACP, 2008).
We sought to describe the epidemiology of HIV in Pakistan and prioritize interventions to improve the effectiveness and efficiency of the response to HIV.
We conducted a systematic review of the epidemiology of HIV in Pakistan. Data sources included PUBMED and EMBASE and unpublished reports from public, non-governmental organizations and provincial and national stakeholders. We focused on findings from the last 5 years and only evaluated data before 2005 on at risk groups where there were insufficient data published after 2005. A population attributable risk analysis was conducted to estimate the burden of HIV among most at risk populations (people who inject drugs, female sex workers, male sex workers, Hijra or transgender sex workers and men who have sex with men).
Pakistan has a concentrated epidemic of HIV-1 among most at risk populations with very low prevalence rates in the general population (0.04%). The majority of current HIV infections are estimated to occur among four at risk populations, despite their accounting for under 2% of all adults. Injecting drug users accounted for 36.4% of HIV cases – the largest share of infections in any one group. Female, male and transgender sex workers accounted for 24%, 12% and 17.5% respectively, a cumulative population attributable risk of 53.5% of all infections occurring among sex workers.
Pakistan must continue to invest in targeted, evidence-based interventions to prevent the spread of HIV and curb the epidemic trajectory in Pakistan. A comprehensive range of services should include needle and syringe exchange, opiate substitution therapy for people who inject drugs, outreach and engagement with injecting drug users, Hijra’ community as well as male and female sex workers and their clients and improved linkage between services and voluntary counseling, testing and anti-retroviral therapy.
HIV/AIDS outbreak investigation in Jalalpur Jattan (JPJ), Gujrat, Pakistan
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Citation Excerpt :
A study done by Bokhari et al. predicted that the presence of high sero-prevalence of HIV among high-risk groups together with unsafe medical injections could be a source of HIV transmission into the general population [14]. Even though HIV-infected persons described in this outbreak investigation are not representative of the JPJ population, nearly equal male to female ratio is different from earlier data reported from Pakistan which showed male predominance [15]. Another important finding of this investigation was the high HIV positivity among children.
In June–July 2008 a non-governmental organization (NGO) in Jalalpur Jattan (JPJ), Gujrat, Pakistan arranged two voluntary HIV screening camps after numerous HIV-infected persons reported to their treatment center in Lahore; 88 (35.8%) of 246 persons screened in those camps were positive by rapid test. Intense media coverage made the residents of JPJ hostile to further inquiries. The Pakistan Field Epidemiology Training and Laboratory Training Program (FELTP) was requested by the Provincial AIDS Control Program to carry out an epidemiological investigation.
HIV-positive persons or family members of patients who died of AIDS and consented to be interviewed during the period 15 December 2008 to 2 January 2009 were investigated. Enhanced contact tracing was done to identify additional cases. A structured questionnaire was used to collect data regarding clinical history, risk factors, and HIV knowledge and practices. The national HIV/STI Referral Laboratory collected blood samples for HIV serology and molecular studies independently following pre- and post-counseling.
A total of 53 HIV-infected persons were investigated. Out of these, 47 (88.7%) were alive at the time of investigation and 27 (50.9%) of the cases were female with 6 children aged 10 years or less. Median age was 35 years (mean 34.7, range 3–70). Most frequent symptoms were unexplained fever 42 (79.2%), diarrhea 34 (64.15%) and skin infections 27 (50.9%); 13 (24.5%) had co-infection with tuberculosis (TB) and 10 (18.9%) with hepatitis (B or C). Use of injections 51 (96.2%), dental procedures 21 (40%) and barber shop visits among males 18 (72%) were common risk factors. Extramarital sex was reported by 4 (9.4%). Only 19 (35.8%) were aware that HIV can be sexually transmitted and 18 (34%) were aware of HIV transmission by blood transfusion. Phylogenetic analysis revealed HIV infection in this group was HIV-1 Subtype A, transmitted over a decade, and the situation is endemic rather than an outbreak.
The investigation indicates high rates of HIV infection in JPJ. Unlike other studies from Pakistan, a high proportion of cases in females and children less than 10 years of age were observed. Socio-cultural norms and stigmatization limited in-depth investigation of sexual and behavioral practices and history of drug abuse. A shift of HIV infection from high-risk groups to the general population was seen and requires vigilant surveillance besides targeted health education, clinical management, lab facilities for diagnosis and monitoring, and voluntary counseling and testing services to limit disease spread.
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An exploratory study of knowledge, attitudes, and practices toward HPV associated anal cancer among Pakistani population
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Personal ViewHIV and homosexuality in Pakistan

Summary

Introduction

Section snippets

Pakistani men who have sex with men: a social perspective

Men who have sex with men demography in Pakistan

High-risk behaviour in men who have sex with men

Controlling HIV/AIDS in Pakistani men who have sex with men

Enferm Infecc Microbiol Clin

Lancet Infect Dis

J Infect

AIDS epidemic update

Sexual behaviour of people living with HIV in London: implications for HIV transmission

AIDS

Sexual orientation and HIV infection prevalence among young Latino injection drug users in Harlem

J Womens Health Gend Based Med

Human immunodeficiency virus associated-disorders in Pakistan

AIDS Res Hum Retroviruses

A study of HIV-antibody sera of blood donors and people at risk

J Pak Med Assoc

HIV risk in Karachi and Lahore, Pakistan: an emerging epidemic in injecting and commercial sex networks

Int J STD AIDS

Pakistan: enhanced HIV/AIDS control program, program implementation plan

HIV/AIDS in Pakistan; the context and magnitude of an emerging threat

J Epidemiol Community Health

The impact of religion and cultural values on AIDS education programs in Malaysia and the Philippines

AIDS Educ Prev

Migrant men: a priority for HIV control in Pakistan?

Sex Transm Infect

HIV/AIDS risk behaviors and correlates of injection drug use among drug users in Pakistan

J Urban Health

High-risk sexual behaviours among drug users in Pakistan: implications for prevention of STDs and HIV/AIDS

Int J STD AIDS

High-risk sexual behaviours among drug users in Pakistan: implications for prevention of STDs and HIV/AIDS

J Pak Med Assoc

High HCV seroprevalence and HIV drug use risk behaviors among injection drug users in Pakistan

Harm Reduct J

HIV/AIDS among men who have sex with men in Pakistan

Sex Health Exch

Personal View
HIV and homosexuality in Pakistan