"This is a disease about dirty people doing dirty things," remarked Mohammad Sohail, 18, a mechanic, displaying his limited knowledge of HIV as he repaired a car outside the bustling Pir Wadhai bus station, one of the largest in the city of Rawalpindi, near Islamabad, capital of Pakistan.
His supervisor, Sayid Ramazan, 26, and the father of two, knew even less. "I never heard of it," he said, scratching his head.
Such responses are not unusual in Punjab Province, where nearly 60 percent of the country's 158 million inhabitants live, but they highlight a serious challenge in the national response to HIV/AIDS.
Pakistan's HIV prevalence rate stands at 0.1 percent but the situation is changing rapidly, with new data revealing that an epidemic is concentrated in two risk groups: injecting drug users (IDUs), and men who have sex with men (MSM).
Prevalence is rising among the country's estimated 150,000 IDUs: in the southern city of Karachi the rate rose from 5 percent in 2002 to 27 percent in 2007, while in the city of Sargodha, about 100km from the capital, it reached a staggering 51 percent in 2007.
In this staunchly conservative society, misconceptions about HIV, coupled with the taboo nature of the groups most at risk, has meant that most cases go unreported; 3,700 cases of HIV have officially been recorded since 1986, when the first one was noted in the southern port city of Karachi, but the World Health Organisation (WHO) and UNAIDS put the real number at around 200,000.
According to the World Bank, underreporting is the result of social stigma attached to the infection, limited surveillance and voluntary counselling and testing services, as well as a lack of knowledge among health practitioners and the general population.
Startling findings in Punjab
At the end of April the Punjab AIDS Control Programme released its survey of eight districts in the province, including Lahore, Sialkot, Rawalpindi, Gujrat, Gujranwala, Faisalabad, Bahawalpur and Multan, which revealed that 87 percent of all respondents had heard of HIV/AIDS.
|Key findings of Punjab survey|
|Of 960 people surveyed, 87% of respondents had heard of HIV/AIDS|
|93.5% of the 449 male respondents and 82.9% of the 395 female respondents had heard about HIV/AIDS|
|The more affluent the respondents were, the more likely it was that they knew of HIV/AIDS|
|TV was the primary source of information about HIV/AIDS (77.6%)|
|Less than 1% of respondents were aware that HIV/AIDS could be transmitted from mother to child through wounds|
|Awareness of other transmission routes were: unsafe sex, 26%; used needles, 23%; and blood transfusions, 6%|
|Only 4% understood that using condoms can be an effective means to prevent infection|
|62% of respondents had never heard about STDs (sexually transmitted diseases)|
|75% of respondents thought that extra-marital sex was prevalent in Pakistani society|
However, less than one percent were aware that HIV could be transmitted from wounds, or from mother to child, while 62 percent had not even heard of sexually transmitted infections (STIs), much less transmission modes or prevention measures.
Although 26 percent were aware that the virus could be transmitted through risky sexual behaviour, and 23 percent knew that used needles could pose a risk, only six percent knew that blood transfusions could also be a mode of transmission, and a mere four percent understood that using a condom could be an effective precaution against becoming infected with HIV.
"What is reflected in the Punjab survey is indicative of the whole nation," warned Fawad Haider, the advocacy focal point for UNAIDS in Islamabad. "We still haven't been able to reach the real people of Pakistan," he explained, referring to the majority of Pakistanis, who live in rural areas.
Most awareness interventions have been targeted at policy-makers and people living in urban areas. "When we target the policy-makers and political leadership, the purpose is to get them to use their positions of influence to spread awareness amongst their constituents, allowing them to go back to the district level ... and spread the awareness at that level," the UNAIDS official said.
Although the strategy of placing the government at the forefront of media awareness campaigns has made some progress, it has not always worked. Moreover, the speed at which awareness levels have increased has been far from satisfactory, and the government has yet to give HIV/AIDS priority on the national agenda.
Hina Rabbani Khar, the State Minister for Economic Affairs and Finance, recently downplayed the significance of the disease, making HIV/AIDS a difficult issue to advocate for.
However, there is some optimism: the government hopes to significantly boost behavioural change among groups deemed most at risk, including female commercial sex workers, MSM, and those born biologically male but who wish to be female, called 'hijras' or eunuchs.
|More on HIV/AIDS in Pakistan|
According to the country's new universal access targets for the next three years, the government aims to reach 25 percent of each of these groups in 2007, with a coverage target of 60 percent in 2010. "I believe we could even surpass those figures," said Dr Nasir Sarfraz, deputy programme manager of the National Aids Control Programme.
A question of resources
Akbar Babar, a private consultant who carried out the Punjab study, said the findings conveyed a stark message that more resources were needed to improve awareness levels nationwide.
"We all know awareness campaigns are expensive; electronic media is expensive, but extremely poor levels of awareness about HIV and its transmission routes should convince policy-makers that we need to allocate a lot more [resources], so that the media reports can be more intense," he said, calling for a significant boost in allocation, particularly for television.
"The only answer is to spread as much awareness as possible," said Haider, from UNAIDS. "The more people know about the modes of transmission, the better the understanding they would have, and the less taboo, stigma and discrimination will be attached to the virus."
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
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