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STIs and HIV in Pakistan: from analysis to action

Understanding sexual health and rights, and identifying feasible and appropriate interventions for improving sexual health and wellbeing benefits from a multidisciplinary approach. A recent study from Realising Rights published as a special issue in the journal Sexually Transmitted Infections seeks to understand the drivers of sexually transmitted infections in Pakistan.

The results of the research suggest three central messages:
1) A window, which is likely closing, exists to prevent a more widespread HIV epidemic in the country.
2) 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.
3) 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.

DFID funded this national survey which was conducted across 12 cities. The survey was co-ordinated by researchers from the London School of Hygiene and Tropical Medicine in collaboration with Pakistan's National AIDS Control Programme. One part of the survey included almost 2,000 sex workers (male, female and transgender) and injecting drug users from 2 cities in the Punjab and North West Frontier Province. While the HIV rate is currently low, the levels of other sexually transmitted infections were high in some groups. For example, close to 50% of the transgender sex workers were infected with syphilis. The survey also found that levels of knowledge about HIV and sexual health in general were extremely low. Perhaps as a consequence, the use of barrier methods such as condoms during sex was also low. Injecting drug users knew more about HIV/AIDS but still resorted to sharing or re-using needles because of the lack of available new ones.

These findings suggest that any future HIV epidemic will be concentrated in the groups with the highest levels of sexually transmitted infections. But that these groups are also among the most marginalised and vulnerable to human rights abuses. Public health interventions with male and transgender sex workers may not win wide approval in a traditional society like Pakistan’s. Political research, funded as part of the study, highlighted the challenges and opportunities to scale up interventions for these most-at-risk populations.

The overall approach of this multidisciplinary study highlights the importance of analyzing STIs and HIV from a variety of interlinked perspectives. In so doing, 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.

Download the papers

STIs and HIV in Pakistan: from analysis to action
Hasan A Zaheer, Sarah Hawkes, Kent Buse, and Michael O'Dwyer
Sex Transm Infect 2009;85 ii1-ii2

Understanding the context of male and transgender sex work using peer ethnography
M Collumbien, A A Qureshi, S H Mayhew, N Rizvi, A Rabbani, B Rolfe, R K Verma, H Rehman and Naveed-i-Rahat
Sex Transm Infect 2009;85 ii3-ii7

HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey
S Hawkes, M Collumbien, L Platt, N Lalji, N Rizvi, A Andreasen, J Chow, R Muzaffar, H ur-Rehman, N Siddiqui, S Hasan, and A Bokhari
Sex Transm Infect 2009;85 ii8-ii16

Prevalence of HIV, HCV and sexually transmitted infections among injecting drug users in Rawalpindi and Abbottabad, Pakistan: evidence for an emerging injection-related HIV epidemic
L Platt, P Vickerman, M Collumbien, S Hasan, N Lalji, S Mayhew, R Muzaffar, A Andreasen, and S Hawkes
Sex Transm Infect 2009;85 ii17-ii22

Modelling the transmission of HIV and HCV among injecting drug users in Rawalpindi, a low HCV prevalence setting in Pakistan
P Vickerman, L Platt, and S Hawkes
Sex Transm Infect 2009;85 ii23-ii30

Protecting the unprotected: mixed-method research on drug use, sex work and rights in Pakistan's fight against HIV/AIDS
S Mayhew, M Collumbien, A Qureshi, L Platt, N Rafiq, A Faisel, N Lalji, and S Hawkes
Sex Transm Infect 2009;85 ii31-ii36

Political feasibility of scaling-up five evidence-informed HIV interventions in Pakistan: a policy analysis
K Buse, N Lalji, S H Mayhew, M Imran, and S J Hawkes
Sex Transm Infect 2009;85 ii37-ii42