Introduction It is estimated that worldwide there are nearly 12.7 million people who inject drugs. The UNODC estimates that Pakistan has 6.7 million drug users, of whom 4 million are addicts, giving us one of the highest number in the world. The UNAIDS Pakistan estimates 1 00 000 people are living with HIV.

Method Our Society provides NSP, condoms, medical care and is linked to Government Victoria Hospital for rehabilitation PWIDs in Bahawalpur, Pakistan.

Results In 2014, we visited 6 drug hotspots and recruited 60 PWIDs. We examined their drug use, sexual risk behaviour, attitudes, HCV and HIV testing experience. Most were males (80%) with a mean age of 30 years (R: 15–54 year), Muslim (92%) and illiterate (55%). All were local Bahawalpur PWIDs, many slept on the streets (83%) and their source of income was scavenging from garbage (88%). PWIDs thought their parents (53%) and the community (56%) hated them. They first used drugs at a mean age 18 years (R: 15–54 years). Most injected Morphine tablets, Pheniramine and Diazepam liquid (90%), many shared syringes (85%) and want to quit drugs (66%). They had stolen to buy drugs (76.7%) and been arrested (26.7%). Most have had sexual intercourse (95%), with sex workers (38%), had a sexual preference for females (73%), but few used condoms (18%) or knew about safe sex (21%), or STIs (33%). Over half had genital itch (58%). Disturbingly few PWIDs knew about HCV (10%), just one person had been tested for HCV (1.7%), yet many were interested in being tested for HCV (85%). Most had been tested for HIV (73%) and many were living with HIV (52%).

Conclusion Pakistani PWIDs suffer many problems, lack access to harm reduction services and are dying from inaction. We recommend urgent action to address this catastrophe in the making.