Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science—as the science of human beings—has the obligation to point out problems and to attempt their theoretical solution. The politician, the practical anthropologist, must find the means for their actual solution.1

More than a century ago Rudolf Virchow, pathologist, physician and politician, argued that progress in public health—while dependent on knowledge generated within specific disciplines—requires, principally, integrated and interdisciplinary approaches, especially if we are to move from the theoretical to the practical.

Heeding this principle, a diverse group of researchers and practitioners sought to understand the drivers of sexually transmitted infections (STIs), including HIV, in Pakistan. The results of the research, presented in this supplement, suggest three central messages. First, a window—which is likely closing—exists to prevent a more widespread HIV epidemic in the country. Second, the need for massively scaled-up interventions is pressing: awareness and knowledge are low, measures to reduce risk are low and levels of vulnerability are high. Third, efforts to ramp up service delivery will need to be matched by deliberate yet ingenious and sensitive work from civil society. Such work will need to confront the social and cultural factors which are at the root of many of the vulnerabilities which will fuel a potential epidemic—from the position of women to the values which drive homosexuality underground to the regulations concerning human rights and the manner in which they are enforced.

The multidisciplinary research presented here was commissioned by the National AIDS Control Programme in Pakistan and funded by the UK Government through the Department for International Development. Academic institutions from Pakistan and the UK joined forces with non-governmental organisations which represented some of the most vulnerable members of Pakistani society. Over an 18-month time frame a variety of separate but interwoven pieces of research were conducted in order to understand the context, extent and complexities of sexual health and sexual risk-taking among people selling sex and injecting drugs. The results of these studies are presented here.

A nationwide mapping exercise (results not published here) found that risk behaviours are widespread throughout the country and that there are significant numbers of vulnerable people in both large cities and small towns. Collumbien et al conducted in-depth qualitative research among sex workers and injecting drug users in the city of Rawalpindi, and their work served to give contextual meaning to reported behaviours and a greater depth of understanding of the lives of members of these vulnerable communities.2 The results of their work further guided the focus of the subsequent bio-behavioural surveys which are reported by Hawkes et al3 who looked at male, female and transgender sex workers and Platt et al who focused on injecting drug users.4 These bio-behavioural surveys confirmed that HIV is not yet widely present among sex workers and injecting drug users in the two cities studied, but highlighted the degree to which high levels of other STIs in some groups, low levels of knowledge among most sex workers and high levels of risk behaviours among all groups will contribute to the overall risk of a more widespread HIV epidemic in the future.

Mayhew and colleagues investigated the extent and context of human rights violations by both non-state (clients, family) and state (police) actors.5 Their work revealed high levels of discrimination and abuse of human dignity. The authors conclude that protection of human rights must become an integral part of any response to HIV and other STIs.

Mathematical modelling by Vickerman et al has shown the potential for reducing the closely related epidemics of HIV and hepatitis C virus among injecting drug users and their sexual partners.6 Even moderate reductions in needle and syringe sharing will have an impact, but only if all users are reached through programmes. The most recent surveillance results suggest that half of all injecting drug users are still not accessing services.7

Once technical evidence had been gathered, suggestions for interventions put forward and subjected to analysis by modelling as well as an assessment of the human rights context, five priority recommendations were agreed upon. Heeding Virchow’s advice for the “politician to find the means to the actual solution”, Buse and colleagues conducted policy analysis to illuminate some of the political dimensions of implementing these five interventions.8 In particular, the political palatability, potential opportunities and opposition to the rolling out of the interventions were assessed and found to be mixed. While some facilitating factors were identified (supportive donors, contracted service providers), many of the proposed interventions were perceived to be at odds with societal values and lacking powerful champions. Buse et al make suggestions on how to overcome these potential barriers.

The overall approach of this multidisciplinary study highlights the importance of analysing STIs and HIV from a variety of interlinked perspectives. Thereby, we may not only identify solutions which are potentially technically sound, but also interventions which address underlying vulnerabilities and may even have a chance of political success and societal acceptance too.

In conclusion, let us return to Virchow, and specifically to his analysis of a typhus outbreak in Prussia written in 1848 which—together with hunger—had killed up to 10% of the populations of some districts that year.

Let it be well understood, it is no longer a question of treating one typhus patient or another by drugs or by the regulation of food, housing and clothing…If we wish to take remedial action, we must be radical …9

A comparison of 19th century Prussia and 21st century Pakistan may be problematic in a number of respects, yet the thrust of the advice remains valid—averting a widespread HIV epidemic in the country calls for more than the distribution of condoms, lubricants and new injecting equipment. A more radical agenda is called for which confronts the norms which currently deprive many of their right health, including their right to sexual health and well-being.