Legitimize use of condoms please, Pakistani researchers have pleaded. In a study published in Lancet online, they have alerted the authorities to the relentless rise in HIV/AIDS incidence. Unless taboos are shed, danger awaits society, they warn.
Carrying a condom is a crime in the country. Those handing out the sheaths, the first line of defence against HIV/AIDS, are at risk of prosecution.
This situation should change and authorities should not close their eyes to the ghastly realities confronting the nation, the experts have pleaded.
After painstaking study, they have concluded that the prevalence of HIV among homosexual and bisexual Pakistani men is reaching alarming proportions. Besides seven times more men are infected with HIV than women.
While there is limited data on risk behaviours and HIV prevalence in Pakistan, there is evidence to show high levels of risk behaviours among vulnerable groups. This includes low condom use among female sex workers and syringe sharing among injecting drug users - both predictors of a growing epidemic. WHO/UNAIDS forecast modeling estimated, in 2002, that there were approximately 70,000-80,000 people infected. What this might mean for young people is uncertain, as no sero- or behavioural surveillance of young people have been conducted.
Because it is legally and socially censured, overt homosexual behaviour can lead to social stigmatisation, class discrimination, ostracisation from family and friends, and, in extreme circumstances, prosecution by law.
And most Pakistanis tend to believe that HIV transmission through illicit sexual activity cannot be a problem in the Muslim world. But, unfortunately, such is not the case at all, the study shows.
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. 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 and thus have a substantial risk of HIV infection.
Also in parts of Pakistan it is traditional to take young boys as sexual partners. In North-West Frontier Province (NWFP) in particular, rich elderly men are known to keep boys for sexual gratification with the thought that women are for children, and boys are for pleasure. When the boys mature, they are abandoned, and sometimes find their way onto the sex trade. A study in 1997 by the National Coalition for Child Rights found that 23% of people in NWFP consider paedophilia a matter of pride, 14% see it as a symbol of social status, and 11% do not consider it wrong. Law enforcement agencies need to offer protection for the boys who are victims of sexual abuse. Furthermore, efforts need to be made towards changing views on this practice, the report stresses.
Despite such a disturbing scenario, knowledge of even sexually-transmitted infections was found to be poor: whereas 43·3% knew they had acquired the infection through sexual contact, 55% men said they did not know the source of infection. Only 28·3% of the study population knew that they could transmit the disease to their partner. Almost all men (93·3%) knew that the infection could be prevented but only 16·7% were aware that the prevention lies in safe sex.
The study on 300 male sex workers in Karachi showed that 79% had heard of AIDS but 42% did not know about its mode of transmission. Additionally, 80% said they had never used a condom.
During interviews with hijras, zenanas, male sex workers, and masseurs, several said that their customers refused to use condoms and paid less for protected sex. It is difficult for these men who have sex with men to convince their male clients to use condoms when the clients could easily find other prostitutes willing to have unprotected sex. Customer refusal to use condoms is mainly based on the concern that condom use compromises sexual pleasure during anal sex.
Fear of poverty, coupled with their stigmatised social status and illiteracy, renders sex workers unable to negotiate safe sex. Some male prostitutes expressed little concern about infecting their clients. According to them, spreading the disease among society would be their vengeance on the very people who have marginalised them.
Interestingly, for some of the male sex workers interviewed, refusal to use condoms was a matter of low self-esteem. They choose not to wear condoms, believing that if they acquire HIV it will be divine punishment for their sinful sexual practices. It is not surprising, therefore, that during our interviews with these groups, they reported high rates of suicide. The overall challenge for intervention programmes thus appears to be to provide care for people who do not care for themselves.
Before devising a programme to work with men who have sex with men and to create awareness among the general population about HIV/AIDS, it is essential to recognise the myths that surround sex and dispel them, say the researchers.
For instance, many of the men who buy or sell sex do not consider anal sex to be a form of sex, and therefore believe that protective measures that ensure safe sex do not apply to anal sex. Any pamphlets, education programmes, or posters that propagate safe sex, therefore, must emphasise the definition of sex itself and identify all practices that will result in transmission of the virus.
Commending some tentative efforts already being made to combat HIV/AIDS, the authors feel what is most important is that policy makers, politicians, and religious figures in the country are sensitized.