Pakistan’s capacity to effectively respond to the HIV epidemic could be hindered due to the lack of resources to implement its revised National Strategic Framework. The framework, endorsed by partners involved in the response, provides evidence-based strategic direction to urgently address the increasing levels of HIV infection amongst injecting drug users (IDUs) and other populations through sexual transmission and avoid a spillover to the general population.

 

 

Despite having an HIV prevalence of less than 0.1% among its general population, Pakistan’s HIV epidemic has transitioned from low to a concentrated one as the overall prevalence among IDUs has steadily increased from 10.8% in 2005 to nearly 21% in 2008.

In part, the region’s comparatively heavy burden of injecting drug use stems from the presence of long-standing trafficking routes for illicit opium. Opiates are the drug of choice for 65% of Asia’s drug rehabilitation patients, although drug use patterns vary greatly within the region. There are an estimated 91, 000 injecting drug users in Pakistan of which nearly one in four in large urban settings are infected with HIV.

Syringe Exchange Programs and Drug Harm Reduction including detoxification programs for IDUs are a priority in light of the epidemic trends among IDUs. Substantial scale-up of harm reduction and HIV prevention services started around 2002-2004 and the country is now set to pilot drug substitution among drug users. Harm reduction services are being implemented by partner NGOs which can play a pivotal role in reaching out and expanding the provision of such services.

Biological and behavioral surveillance studies have shown an increase in knowledge regarding HIV, increase in condom use and decreased sharing of syringes/needles among IDUs exposed to risk reduction program activities. However, coverage of these programs is still low. An increase in resources available would expand the provision of risk and harm reduction services that are producing positive results mitigating the spread of HIV among populations at higher risk.

Knowing your epidemic

Following the trend seen in other countries in Asia, also known as the Asian Epidemic Model, the epidemic in Pakistan is characterized by the rapid HIV transmission and high prevalence among IDUs in the initial stages and potential spill-over into other key populations at higher risk such as sex workers and men who have sex with men (MSM). Subsequently, through bridging populations such as partners and clients of sex workers, the epidemic could find its way into the general population. The connections and overlap between drug use and sex work coupled with high prevalence of unsafe sexual practices and low self risk awareness indicate that there is potential for rapid spread of HIV infection among key populations.

One of the implementation successes in the country is the 2nd generation surveillance for tracking trends in the epidemic. A country specific methodology has been developed, with mapping of risk groups in the first phase and collection of behavioral and biological data after mapping has been completed. This has provided up to date information on size of risk groups as well as on HIV prevalence among them.

Epidemiological evidence gathered over the last years has therefore confirmed Pakistan’s ‘concentrated’ epidemic. It has also underlined the low levels of adoption of HIV prevention measures in the general population and among youths.

Adapting the response

In line with the epidemic trend, supported by results from recent surveillance data, the Government of Pakistan has recently reviewed its National Strategic Framework (NSF-II). The new five year initiative (2008 – 2012) builds upon the initiatives outlined in the first national framework and renews focus towards rapidly scaling up prevention and HIV service delivery programs for most at risk populations.

The country has drafted its national AIDS policy and legislative framework, through the ‘HIV & AIDS Prevention and Treatment Act’, in order to support the government in providing services to populations at risk of acquiring HIV infection due to their occupation and/or practices. The basic provisions of the policy are intended to guarantee access to care, support and equitable access to treatment for people living with HIV. It is also intended to reduce stigma and discrimination against people living with HIV as well as to improve access to HIV specific information and prevention services.

“Pakistan has made substantial progress over recent years, including in addressing sensitive social issues and increasingly involving people living with HIV in the forefront of the AIDS response” says Oussama Tawil, UNAIDS Country Coordinator, “however, it is now critical that a collective effort be made to sustain the momentum in these life-saving measures”.

Lack of resources

Despite having a thorough plan of action built upon evidence-based recommendations, the country is facing a shortage in resources that could jeopardize an effective and timely response to the epidemic.

A costing exercise undertaken by the Government estimated that the total fund requirement to implement the NSF II is US$ 293 million over five years. During 2006-2007, AIDS expenditure totaled US$ 29.67 million, with prevention-related activities having been allocated the biggest share (61%).

While resources have been made available to the country by the World Bank, bilateral funding and government resources, these funds are insufficient to cover the current needs and to create a sustainable long-term capacity to address the HIV response in the future.

AIDS could have a severe impact in certain communities over the coming decade. Financial and human resources are urgently needed to scale-up the provision of HIV prevention, treatment, care and support services in order to have a definite impact on the HIV epidemic and to mitigate its social and health consequences.

In a move to counter social exclusion and change discriminatory practices, a dialogue has begun in Pakistan between the government, parliamentarians and communities often overlooked by policymakers. An historic meeting was held late last month when a number of parliamentarians began a dialogue with community members on the challenges facing transgendered people, people who use drugs and people living with HIV. This meeting was a first, and aimed to create an enabling environment for policy changes related to HIV.

Among the general population in Pakistan HIV prevalence is less than 0.1%, however results from the recent HIV Second Generation Surveillance in the country indicate that injecting drug users and the transgender community are the two populations with the highest rate of HIV infection in the country, with an estimated 20% and 7% prevalence respectively. HIV infection is not the sole concern of these populations who can also be caught up in a cycle of social and economic exclusion exposing them to marginalization and violence, limited access to health and others services, and, for drug users, a lack of drug substitution programmes.

The dialogue, held at a parliamentary sub-committee level, brought together parliamentarians from across party lines; associations and groups representing people living with HIV such as the Red Ribbon Initiative, Pak Plus and New Light AIDS Control Society; the Sathi Foundation for transgenders; as well as Nai Zindagi, an organization that provides services for drug users.

It was also an opportunity for parliamentarians to discuss with senior police, narcotics control and health officials who were present the need for changes in policy and practice towards key groups. Discussions ranged from an urgent call to push through pilot substitution therapy which is still awaiting final government clearance, to introducing a special focus on transgender within police training and investigations on sexual violence and abuse perpetuated against them.

The government of Pakistan already endorses harm reduction within a wider approach to drug prevention and control, and non-governmental organizations collaborate closely with the Ministry of Health on needle exchange programmes.

Discussions also touched on issues affecting the general population. People living with HIV in Pakistan risk losing their employment or at times refusal by health workers to provide care to them; and people working overseas such as in the Gulf States have faced deportation back to Pakistan once detected HIV positive.

The Pakistan government’s response to HIV began in 1987 with the establishment of a Federal Committee on AIDS by the Ministry of Health, soon after the first case of AIDS was reported. Today the country’s National AIDS Control Programme is implemented through federal and provincial implementation units.

Funding gap

However Pakistan is currently facing a considerable gap in funding the scale-up of community-based efforts which represent the backbone of the national AIDS response. The country benefits from donor support, in particular from the World Bank, UK and other bi-laterals to scale up HIV prevention, treatment, care and support. Despite applications for resources from the Global Fund to Fight AIDS, TB and Malaria in recent years, grants on HIV have yet to be secured though needs are clear.

Speaking during the meeting, Member of the National Assembly and Chair of the Parliamentary Sub-Committee on AIDS, Dr Donya Aziz said, “Donor support is essential for us at this point, yet, in the long run, we cannot rely on external funds. Public and private sectors must mobilise resources, while policy decisions are needed to ensure services and to address social exclusion in our communities.”

In spite of the challenges ahead, participants at last month’s gathering felt that the breakthrough in challenging mistrust towards communities heralded by this meeting is an important milestone on which progress can be built.

The dialogue is just the beginning and will be followed up with a series of meetings to be held among a larger forum of parliamentarians across party lines and civil society groups. Hopes are high that policy change and attitude change will also follow.

UNAIDS Country Coordinator for Pakistan Oussama Tawil echoes this hope, “Leadership shown by a few, through a courageous dialogue with parliamentarians represent a voice of change for countless others.”

Asian women migrating to the Arab states often do so under unsafe conditions, are targets of sexual exploitation and violence and are highly vulnerable to factors that lead to HIV infection, according to a study launched today, produced in collaboration by UNDP, UNAIDS, CARAM Asia, IOM,UNIFEM, and Caritas Migrant Centre in Lebanon.

HIV Vulnerabilities of Migrant Women: from Asia to the Arab States examines the health, social and economic toll that migrant women often face, particularly those who are low-skilled. In the current global economic crisis, with rising unemployment, their situation can become precarious as they tend to be in a weak bargaining position and are more likely to accept poor conditions to secure or keep a job.

Migration itself is not a risk factor for HIV infection, but it is the conditions under which people migrate, and the working and living conditions they find themselves in that make them highly vulnerable to HIV.

Based on some 600 interviews in four Asian countries and three Arab states (Bahrain, Lebanon and United Arab Emirates), the study reveals that migrant women, many of whom become domestic workers, often lack legal coverage, suffer duress and sexual exploitation in the workplace, and have limited or no access to health and social services.

The Arab States are the primary destination for many migrant workers from Asia, including the four countries which are the focus of research; Bangladesh, Pakistan, the Philippines and Sri Lanka.

The movement of women and money between the countries studied is considerable. The report estimates that 70-80 percent of migrants from Sri Lanka and the Philippines to the Arab States are female. Between 1991 and 2007, 60 percent of women migrants from Bangladesh left to find employment in these countries and remittances from Filipinos working in the Arab States in 2007 amounted to US$ 2.17 billion. In Bangladesh, migrant workers sent back close to US$ 637 million from the UAE. Current remittances by migrant workers from Sri Lanka amount to US$ 3 billion.

HIV Vulnerabilities of Migrant Women: from Asia to the Arab States charts a way forward. According to the report, host countries and countries of origin share equal responsibility to provide protective policies and programmes for women who seek a better life away from home. Recommendations include:

 

• Migrants who have a medical condition that does not impair their ability to work, such as living with HIV, should not be denied the right to work
• Health insurance schemes for migrant workers should cover all aspects of health, including HIV
• Hiring agents and employer blacklists need to be created, monitored and shared
• Embassy and consular staff in host countries should be trained on the special needs and vulnerabilities of migrant women
• Existing labour laws should be changed/reformed to cover migrant workers in the domestic sector

Bats flashing. Balls flying. The three young boys, their fingers intertwined in the links

of the wire-mesh fence, watched mesmerized as some of their cricket idols trained on a pitch just outside of Johannesburg in South Africa.

 

The Pakistan cricket team had invited the youngsters from loveLife – the national HIV prevention programme for young people in South Africa – to their training session in support of the International Cricket Council’s partnership with UNAIDS and UNICEF to bring attention to the situation of children and young people living with or affected by HIV.

 

The Pakistan cricket team is among 12 world teams currently gathered in South Africa to play in the inaugural ICC World Twenty20 2007, which is being held at various locations throughout the country from 11 to 24 September.

 

Coming off the pitch after their practice session, the cricketers took time to sign commemorative bats, take photos – and talk to the young boys about the importance of HIV prevention.

 

“Be safe. Be strong. Love life!” said Shoaib Akhtar, arguably the fastest cricket bowler in the world and a clear favourite of the young fans.

 

“AIDS is a challenge for all countries in the world, and especially for cricket-playing countries, which are among the most affected by HIV,” added Kamran Akmal. As the AIDS Ambassador for the Pakistani team, Kamran devotes much of his time to HIV-related activities in his home country, spreading the ‘Play safe’ message. “It must be our common goal to defeat HIV.”

 

Some 40 million people in the world are infected with HIV – nearly 15 million of them living in cricket-playing countries.

 

Pakistani captain Shoaib Malik was the first player to arrive for the training session and the last to leave – a reflection of his responsibility as team leader. “Being the captain of the team is a difficult job. It means giving 110 percent. But strong leadership is important to the performance of any team. It is also important that we show leadership as role models for young people through the world and we are proud to be part of the ICC partnership with UNAIDS and UNICEF.”

 

Pakistan stars and other top players, including South African captain Graeme Smith, Kuman Sangakkara of Sri Lanka and India’s Yuvraj Singh will feature in public service announcements for the ‘Unite for Children, United against AIDS’ global campaign highlighting how HIV impacts on the lives of young people. These will be made available to broadcasters in 105 countries across the world as well as being watched by fans on the big screens at the 27 matches during the tournament.

 

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Links:

Read more on the ICC Twenty20 World Championships
Read more on Unite for Children: Unite against AIDS

A new national initiative from UNAIDS in Pakistan aims to ensure that communities and the government listen to the experts - people living with HIV - when making decisions about treatment, care, support and prevention.

Twenty-four year old Masood is the newest recruit to one of UNAIDS’ latest initiatives: the“Association of People Living with HIV and AIDS in Pakistan”.

The association was launched on World AIDS Day 2006 with the support of UNAIDS and its UN co-sponsors, and the Pakistan government. The aim is to make sure that people living with HIV are consulted when decisions about prevention, treatment, care and support are taken at federal and provincial level.

In keeping with the principle of greater involvement of people living with HIV, all the executive board members of the association are HIV positive. Now, it is establishing the first network among people living with HIV in Pakistan to provide a platform for them to speak in unison.

“In my experience, most HIV positive people here have difficulty conveying their needs, often because of poverty and because the literacy rate is low and information provided is limited,” says Masood.

“Here in Pakistan HIV is not seen as a priority and people have many issues surrounding their treatment, care and support, stigma and discrimination and society’s attitudes.” Stigma and discrimination is specifically associated with children and women from rural areas of Pakistan. These women have been infected by their husbands; most of them were migrant workers who have been deported by certain countries without being told about their HIV positive status.

The Association has already begun to bring the small number of NGOs and self-help groups together. The objective is to provide training in leadership skills and health information, including adherence to anti-retroviral treatment.

With a Masters in Business Administration from University in Lahore, Masood is working with them to organize themselves strategically, to develop policies and to raise funds.

There has been a three-day workshop on capacity building already, focusing on the issues for people living with HIV in Pakistan and how to operate an effective positive self-help group. Another two-day workshop focused on HIV literacy helped pre-testing and collecting feed back on the newly developed booklets and other information materials produced in Urdu and English for people living with HIV (PLHIV).

UNAIDS will be supporting more workshops across the country and is planning to do this activity in collaboration with Association of PLHIV, provincial and federal Government and civil society organizations working on AIDS issues.

“We aim to contribute to improving people’s lives, give them a sense of belonging, political empowerment and strength of spirit,” says Masood.

At the same time the Association aims to contribute to the national goal – to “prevent a generalized epidemic in Pakistan by containing the spread of HIV and AIDS and elimination of stigma and discrimination against those infected and affected” .

*The country's epidemic is concentrated and intensifying. Pakistan has one of the highest rates of injection drug use in the world (4.5 per capita per annum), and 64% of injecting drug users report use of non-sterile needles. Frequent use and reuse of unsterilized and contaminated needles contributes to a high transmission rate of HIV among injecting drug users (10%). The World Health Organisation and UNAIDS estimate the actual prevalence may be as high as 85,000 (46 000- 210 000).

During the Launching ceremony of Association of PLHIV in 1 st December, 2006 Dr. Aldo Landi, UNAIDS Country Coordinator said:

“This is the first step as a breakthrough in the fight against stigma and discrimination”. He further expressed the need of involvement of PLHIV at both federal and provincial level. Most importantly PLHIV should be treated in full respect of human rights.

Masood is a hemophiliac who contracted HIV through infected blood. In Pakistan, about 50 per cent of blood products are screened for HIV before blood transfusion – and 1.5 million blood bags are transfused every year. About 18 per cent of people living with HIV in Pakistan were infected in this way.

“I am very ambitious because I am facing and feeling the pain,”says Masood. “I want to make a real difference by encouraging people living with HIV to realize how important it is for them to be involved at every level.

“They themselves will bring about change. I am happy to be the first drop of rain.”

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Links:

More information on Pakistan
Visit UNAIDS Pakistan web site
Read the report - Implementing the UN learning strategy on HIV/AIDS: Sixteen Case Studies

Despite the low HIV prevalence in South Asia, the epidemic continues to spread unabated, particularly among high-risk groups. In an effort to accelerate and strengthen the response to AIDS in the region, the South Asian Association for Regional Cooperation (SAARC) has taken a significant step forward by signing a memorandum of understanding with UNAIDS today.

London/Geneva, 13 April 2004 – Players from the India and Pakistan cricket teams will wear the symbolic red ribbon as part of international cricket’s commitment to raise awareness about HIV in today’s third Test match, being held in Rawalpindi, Pakistan. As part of this ground-breaking initiative, the team captains will also be accompanied by an HIV-positive person for the coin toss before the match.