Daily Times

Denied for long as an alien tragedy, the deadly virus has found a home ground, and with quick diffusion, Pakistan is now a high-risk country. Sensationally demonising one doctor, one district and scapegoats disguise the real magnitude and apathy towards the problem. Approximately, there are 163,000 HIV/AIDS cases with only 25,000 registered. If the factors causing Hepatitis C are the same as of HIV/AIDS, then the actual decimal could be much higher.

Sexually active transgender people, injected drug users (IDUs), long-distance drivers, and commercial sex workers (CSWs) constitute high risk communities. Socioeconomic inequalities, illiteracy, women’s lack of control over their body, growing sex industry, unsafe blood transfusion, ill-trained quakes and paramedics, use and reuse of unsterilised syringes, unregulated medical stores-cum-blood banks, and faulty infection control practices deepen the diffusion. Mobile labour, border-area refugees, aversion from screening, micro-macro politics, and associated myths pose additional challenges. A lukewarm governmental response and low priority with extremely distressing demographics compound it further.

In this context, quick findings of a small-sample research study in Abbottabad, Sanghar, Multan, and Rawalpindi that I was involved in last year are worth sharing.

Poverty and lack of awareness about HIV/AIDS transmission and control run side by side. Out of 33, 26Persons Living with HIV/AIDS (PLHAs) from Rawalpindi earned less than Rs 20,000 a month. Poorer individuals, once infected, lose psychosocial support; they also fail to secure treatment.21 of them were either matriculate or even below, and four had never gone to school.

“Discovering my status”, said one of the affectees from Sanghar, “I now have sex only with boys as it is safer. Several times, my friends and I perform with the same boy, one after the other.”

In Abbottabad, six out of 20 truckers had no idea that blood transfusion was a major source of contracting HIV/AIDS. They also did not know that Hepatitis C and TB were also transmitted through blood. Out of the 20 IDUs interviewed from Multan, 10 had not gone through any rehabilitation or screening exercise, while 10 out of the 30 affected persons from Rawalpindi were IDUs.

Out of the 20 affectees in Abbottabad, 11 had heard of it only from friends and family, five from clergy, and three from radio. Referring to Maulana Tariq Jameel, one of the respondents believed that “deserting the path of Islam, Muslims were contracting AIDS. Modern science failed to cure it as the sinners were decreed to be punished by God.” Only two out of the 20 truckers thought that injected drugs could also transmit HIV.

Out of the 20 affectees in Sanghar, nine, out rightly, refused to interact. Those who agreed were relatively educated and were on anti-retroviral(ARV) therapy. Medical stores, staff of private clinics and IDUs were found maintaining a vicious business cycle in the district. Stores sell drugs and syringes to clinics, and the staff sells them back at a lower price to IDUs. Informally, some health professionals of the Civil Hospital provide basic training of applying drips and injections to young boys for Rs7,000-8,000for a week; once trained, they start working in private clinics right away. Only 20 out of 30 private clinic assistants were either doing or had just done their matriculation, while the rest were enrolled in intermediate without getting through.

Much of the shock and horror of HIV and AIDS circle around sexuality. Otherwise, there are equally communicable diseases like TB, Hepatitis B and C that also need precautions

Obviously, such people are little familiar with precautionary measures.12 out of 30 such practitioners disposed off used syringes by throwing them into dustbins. Garbage collectors collect and sell them back to IDUS.A prick of a needle is a common accident that puts them at the risk of contamination.

Inquiring, only18 out of 30 paramedics appeared to have crude know how of HIV/AIDS, while only 12possesseda relatively better understanding. 18 out of 30 paramedics simply failed to define HIV/AIDS; six termed it to be a bacterial disease, five as viral and to one of them, it was combined.10 of them thought it was curable, and around 17 had no opinion. Two out of 20 paramedics from Abbottabad thought that sexual intercourse was not a source of communicating HIV. To one of them, HIV did not transmit through blood transfusion, while one of them thought a syringe could be reused simply by washing it. 16 out of 20 paramedics believed the virus could be transfused by breastfeeding. Five of them believed that HIV could be transmitted through deep kissing. Two midwives I conversed with knew nothing about HIV/AIDS.

Seven out of eight women from Rawalpindi contracted it from their husbands working in the Gulf countries. None of them knew their spouse’s status in advance. “He himself perished leaving me back with this curse,” bemoaned one of the women. “Initially, when I discovered the shocking fact”, said a woman from Sanghar, “I was quite concerned but then I submitted myself to the will of God.” “Usually high on drugs while having sex, my husband almost never uses a condom”, said the wife of another HIV+ man. “When I came to know about my husband’s infection, first I began avoiding him, but then I realized that Islam awards men rights over their wives. Now I cooperate, but he uses a condom.”

Regarding sexuality, women rarely exercise their will. Given their biology, they acquire infection faster. Mother-to-child transmission is quite likely due to a baby’s exposure to mother’s blood in the pre-natal period. Infant-to-mother transmission also depends on the mother’s stage of infection. Though the chances are slim but breastfeeding may also cause it. Women dependency on men, lack of knowledge, limited mobility, socio-religious obligations, inability to negotiate with their partners, and child rearing responsibilities render them further vulnerable.

Risk perceptions derive from belief systems, reinforcing socially sanctioned behaviours. Interpreted as a divine curse or punitive justice, the disorder is then followed by anxiety, taboo, shame, and discrimination. Given the patriarchal monopoly over sexuality, HIV+ women are stigmatised more than men. Many ordinary citizens falsely hold that HIV/AIDS is transmitted by shaking hands, hugging, kissing, sharing utensils, food, clothing, beddings, towels, by using the same toilets, and even by working side by side a PLHA. “God detests adultery, sinful sexual pleasures, and un-Islamic behaviour, hence inflicts the trespassers with HIV/AIDS”, many of them argue. In fact, avoidance, xenophobia, depression, trauma, and lower self-esteem kill them faster than the virus itself.

“Our relatives”, wailed an HIV+ woman from Sanghar, “neither invite nor visit us anymore. No one allows me to play with their children.”  “My family separated all my stuff and my room, once they discovered that I was HIV+”, said one of the respondents from Multan. “Having acquired the disease, I wished to learn certain religious rituals, say, bathing the dead, but I was refused,” he added.

Despite the gloomy state of risks and stigmatisation, all is not dark. No cure available so far, but ART and family-cum-societal support can help PLHAs to live relatively healthier, happier and productive lives for years, even decades. Firm commitment to ART ca nalso halt the transmission and progress. Affected mothers can prevent the transfer to their babies. Those accidentally exposed to should immediately take PEP (post-exposure prophylaxes) to prevent diffusion. Unless required to save life, injections should be avoided, and blood must be thoroughly screened before transfusion.

Understanding the connectivity between health, wellbeing, socio-cultural constructs, and politics of bio-scientific issues can help deal with the enigma. Specific insights and messages need to be communicated to those affected as well as to the general public. Much of the shock and horror of HIV and AIDS circle around sexuality. Otherwise, there are equally communicable diseases like TB, Hepatitis B and C that also need precautions.

Adequate bio-medical legislation is desired to discourage stigma and set standards for professionals and paramedics. An intensive and extensive anthropological study is required to assess the associated predicaments and avenues of intervention. Understanding, precautionary measures and preventive capacity of private practitioners need to be enhanced. GOs and NGOs need to devise general and customised campaigns for truckers, transgender people, barbers, blood bankers, IDUs, emigrants, and CSWs.

The difference between HIV and AIDS, along with means of transfusion, need to be clarified to the general masses. The affectees need socio-psychological and economic assistance. ‘I am HIV positive, touch me’ has been a successful slogan in some countries to change public perceptions. Impression of the affectees being ‘the immoral others’ must be eliminated to promote equality, mutual respect and human dignity.

Considering gender norms, women-specific programmes should be designed. Individuals and discordant couples need psychosocial counselling to normally engage in their day-to-day activities. High-risk-mothers must avoid alternating breast and bottled milk as it multiplies the risk of transfusion. Assess their actual number and the affectee status rather than turning a blind to eye to CSW sin the country. Instead of harassing and brutalising, they need education for a safer sexual engagement. Those forced into the industry ought to be liberated and rehabilitated by introducing them to alternative skills and occupations.

Also, Pakistan may opt for a policy position to compel the Gulf and other countries to treat affectees in their own countries rather than deporting them. However, along with economic repercussions, their intermittent visits back home needs exhaustive deliberation.

Precisely, without massive policy and programmatic measures at the state level, halting the march of this menace is not possible. Embedded in socio-cultural context, integrated programmes with adequate financial provisions are essential. National and provincial AIDS control programmes (N/PACP) need to be given a comprehensive package of prevention, treatment, care, and support. Existing ARV, prevention from parent to child transmission, community and home-based care services need expansion in outreach, equipment and resources. N/PACPs need to take maximum benefit from UNAIDS and WHO’s technical expertise and assistance. In place of paltry and provisional assistance, the third Strategic Framework (2015-2020) needs to be allocated its entire budget as planned in the PC-1, if any seriousness  persists up there to deal with the problem.

The writer is based in Islamabad. He is Executive Director at the Institute of Development Research and Corresponding Capabilities (IDRAC)