While government statistics state that the rate of HIV/AIDS infection in Pakistan is extremely low, humanitarian workers suggest that social and population trends combined with a culture of denial on the AIDS issue mean there is a real danger of a large-scale epidemic in the longer term.
Pakistan’s records state that there were just under 1,700 cases of HIV/AIDS, in a population of over 150 million, as of September but UN sources told IRIN this week that there closer to 80,000 people living with HIV. UNAIDS, for its part, has estimated that the number of people infected with HIV/AIDS at the end of 1999 was about 74,000, and that the disease accounted for some 6,500 deaths last year. [for details, go to: http://www.unaids.org/hivaidsinfo/statistics/june00/fact_sheets/]
According to UNAIDS, the number of officially recorded cases may be low for a combination of reasons, including: the epidemic being in its early stages in Pakistan; widespread under-reporting of cases due to inadequacies in the surveillance system; and limited care-seeking by individuals due to ignorance or the social stigma surrounding the disease.
Despite an adult rate of infection currently estimated at just 0.10 percent, the danger of HIV/AIDS is quite real in Pakistan, according to UNAIDS. “As has proven true in other countries, an HIV/AIDS situation of ‘high-risk/low-prevalence’ can very quickly change to one of ‘high-risk/high-prevalence’,” which could be a disaster for Pakistan, the agency states.
Sixty-three percent of Pakistan’s population of over 150 million is below 25 years of age, and it is this group - the most economically productive segment of society - that runs the highest risk of infection. The social and economic dimensions of the HIV/AIDS pandemic could be disastrous in Pakistan if the spread of the disease is unchecked.
In the Urdu language, the word ‘amal’ means action, and the Pakistani nongovernmental organisation Amal is demanding just that. Since 1994, the Islamabad-based NGO has been very involved in promoting AIDS awareness in the community, and in trying to convince the authorities of the threat the disease poses not just now, but for Pakistan’s development and future.
Deputy Director Anwar Naeem told IRIN on Monday that, to begin with, Amal faced a great deal of resistance. “Talking about sex and sexuality is a sort of taboo in Pakistan. The AIDS problem here is extremely serious due to a variety of issues, and is aggravated by outright denial. As far as our sexual activities are concerned, in Pakistan people don’t like to talk about it, and this is the main problem - the main barrier to HIV awareness.” [AIDS, the Acquired ImmunoDeficiency Syndrome, is the late stage of infection by the Human Immunodeficiency Virus, HIV]
“As far as Pakistan is concerned, AIDS is not just a disease - it is a development issue,” Naeem said. If you are going to have a large scale epidemic occurring in your country, what is it going to mean for the long-term development and future of Pakistan?”
While young people have always been the focus of Amal’s activities, women are also a particular target group. “We chose women because of their position in Pakistani society and their vulnerability,” Naeem explained. “In Pakistan, women have no decision regarding their body, no say about their sexual activities ... We also feel we can sensitise more women than men about the disease in a shorter period of time.”
Dr Kristan Schoultz, country programme adviser for UNAIDS in Islamabad, told IRIN on Wednesday that Pakistan’s vulnerability to HIV/AIDS had to be understood against “a backdrop of poverty, gender inequality, and political instability.” The UN estimates that 34 percent of the population lives below the poverty line, and a substantially higher percentage in rural areas. This poverty, in turn, restricts people’s access to education and other social services, which might help to protect them from AIDS.
People who are marginalised economically often make decisions and do things that they would not do if their situation was otherwise, Schoultz said. Although prostitution is illegal in Pakistan, a thriving commercial sex industry can be found servicing traders, truck-drivers, seafarers, migrant workers and visitors from other parts of the country in most of Pakistan’s major cities, he added.
In 1996, Amal initiated an AIDS awareness programme targeting 2,000 of an estimated 5,000 sex workers in the notorious ‘Hera Mandi’ district of Lahore, provincial capital of the Punjab. Using a group of 15 former prostitutes trained in AIDS awareness, Amal worked hard to educate commercial sex workers on high-risk behaviour patterns and the need to use condoms.
One study cited in a UN situation analysis indicated that only 24 percent of Pakistani couples reported using contraceptives on a regular basis. The reasons for this were varied, but social, cultural and religious factors often influenced whether contraception use was even discussed. While condoms were the most popular contraceptive measure used in Pakistan - available everywhere and distributed by both governmental and NGO clinics throughout the country - they were still promoted primarily for family planning rather than to prevent disease, it said.
According to the UN analysis paper, “the story of Pakistan’s governmental response to the HIV/AIDS crisis is one of good intentions thwarted by limited and inconsistent political resolve and a scarcity of financial resources.” NGOs are almost uniformly critical of the government’s response.
Although Pakistani authorities recognised the threat and established the National AIDS Programme (NAP) in 1988 following the first diagnosed case in 1987, recent years have seen declining political commitment and funding. Since 1996, budget allocations to NAP have dropped substantially. Of the $816,000 equivalent allocated between 1997 and 1998, only 50 percent was actually released. This inadequate financial support has subsequently weakened efforts to prevent and control the further spread of HIV/AIDS in the country, and NAP has yet to recover.
However, Dr Berjees Kazi, Country Manager of NAP, told IRIN on Wednesday that “there are additional factors beyond funding,” such as social and educational issues. “Most of the time when people comment on AIDS in Pakistan, they target the efforts of the government, which is wrong.
Ironically, regarding all the money that is spent on AIDS and HIV in Pakistan, 90 percent comes from the government, with only 10 percent coming from international donors and the community,” Dr Kazi said.
Asked what role NGOs played in AIDS awareness in Pakistan, Kazi said:
“NGOs and groups within the community are essential... We need to build up the capacity of these groups, give them additional training and education. This is precisely the area in which international donors could be of greater assistance to the government’s efforts.”
Schoultz, too, emphasised the role of the non-state sector. “NGOs are vitally important to the response in Pakistan,” given the size of the country and their access to the community, he said. At present, there are some 72 local and international NGOs involved in AIDs-related activities in Pakistan. While their resources are limited and their programmes limited in scope, they are involved in a wide range of HIV/AIDS prevention initiatives making their role significant, he added. Although NAP has had success in some areas, “the challenge posed by the epidemic cannot be countered by governmental effort alone,” Schoultz added.
One NGO trying to make a difference, and desperate for funding - it receives no financial assistance from the government or any donor agency - is the Lahore-based ‘New Light’ group, one of the few NGOs that works with people who are living with AIDS.
Programme director Nazir Massih, himself HIV-positive, told IRIN that the social stigma of living with AIDS in Pakistan was “devastating”, and had led him to establish the support group in 1999.
“Doctors began playing with my life, constantly changing their statements about my condition from one day to another, even telling my family to avoid contact with me,” he said. “In Pakistan, if you are HIV-positive society looks upon you as an animal, something ugly... people avoid you and the press publish pictures of you in the newspapers.”
‘New Light’ actively seeks out people who are HIV-positive in schools, factories and the community at large to raise awareness and to give counselling to those who are infected, and their families, most of whom are quite poor. Ninety percent of the people do not even have the most basic information about HIV/AIDS, according to Massih. “When an infected person dies, the family often hesitates in bathing the body as tradition demands, at which point we do it and arrange for the individual’s burial,” he said.
While the building blocks of a successful response were in place, Pakistan was still highly vulnerable and HIV/AIDS campaigns needed to be greatly expanded, Schoultz told IRIN. “More resources need to be allocated to HIV/AIDS initiatives, awareness levels in both the general population and among specific groups who are especially vulnerable need to be improved... In short, we have a great deal to do and, possibly, not much time to do it.”
Above all else, Pakistan faces a real problem with the long-term implications of denial, according to Naeem. “The present situation in Pakistan is very similar to the situation of India seven or eight years ago. There was no government commitment and people were in denial,” he said. According to the UN, India now has the second largest population living with AIDS (after South Africa). About 3.7 million people are reported to be living with HIV/AIDS in India and a widespread heterosexual epidemic is feared.
“Our cultures are quite similar and AIDS recognises no borders or barriers,” said Naeem. “If we are not committed both on the government and community level to raising AIDS awareness in this country, we are going to be facing the same dilemma that faces India today.”