Objectives: The extent and possibilities of spread of the HIV epidemic are not fully understood in Pakistan. A survey was conducted among men, women and transgender populations selling sex in Rawalpindi (Punjab) and Abbottabad (North West Frontier Province) in order to inform evidence-based programme planning.
Methods: A cross-sectional survey was performed with participants recruited through respondent-driven sampling. Male and transgender sex workers were analysed in three gender groups; women were analysed as one group. Behavioural surveys were conducted and clinical specimens collected. Laboratory tests looked for evidence of acute infection (gonorrhoea, Chlamydia, syphilis, Trichomonas) and infection over the lifetime (HIV, herpes simplex virus-2, syphilis). Predictors of infection were explored using univariable and multivariable logistic regression.
Results: The prevalence of HIV was low in 917 male and transgender sex workers and absent in 533 female sex workers in the study. High levels of current sexually transmitted infections were found, predominantly among transgender sex workers. Risk behaviours were common and knowledge of HIV was extremely low. Multivariable analysis found a large number of factors associated with higher levels of infection, including experience of forced first sex. Protection against risk was low, but those sex workers who reported using condoms at last sex had lower rates of infection.
Conclusions: The HIV epidemic is currently in its early stages among people who sell sex, but there may be potential for a much greater spread given the levels of other sexually transmitted infections found and the concomitant low levels of both protective knowledge and risk-reducing behaviours. Action is needed now to avert an epidemic. Framing interventions by upholding the recognition and protection of human rights is vital.
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Funding: This study was funded by the Department for International Development (UK).
Competing interests: None.
Ethics approval: The study was undertaken with ethical approval from both Nai Zindagi Institutional Review Board (in Pakistan) and the London School of Hygiene and Tropical Medicine (in the UK).
Contributors: SH, principal investigator, contributed to the design of the survey and survey instruments, coordinated survey implementation, interpreted data and was lead author on the paper. MC contributed to the design of the survey instrument, analysed and interpreted the data for MTSW and contributed to several drafts. NL contributed to the design of the survey instrument, was responsible for project implementation in Pakistan and contributed to the writing of the paper. LP cleaned and coded all the datasets, led the analysis for FSWs, wrote the methods and contributed to the writing of the paper. NR contributed to the design of the survey instrument, assisted with project implementation in Pakistan and contributed to the writing of the paper. AA contributed to the development of the laboratory methods and the writing of the paper. Hur-R was responsible for project implementation in Rawalpindi. NS was responsible for project implementation in Abbottabad and contributed to the writing of the paper. JC was responsible for data analysis and review of the manuscript. RM was responsible for laboratory inputs. SH contributed to the design of the survey and implementation of the project in Rawalpindi and Abbottabad. AB contributed to the design of the survey, facilitated survey implementation in Pakistan and contributed to several drafts of the paper.