Identification of novel silent HIV propagation routes in Pakistan

Abstract

Human immunodeficiency virus (HIV) is rapidly increasing in both high risk groups and the general population. In this study, silent routes of propagation in teenaged Pakistanis are discussed. In order to promote sexual activity in youths, regular clients write contact details of sex workers on the doors of public washrooms. HIV prevalence is much higher among Hijra sex workers. Hijra sex workers have apparently stepped into the profession of begging at public places, where they earn money by both begging and distributing visiting cards offering unsafe sex. In many educational institutes, sex education is lacking or absent; if delivered via teachers, government agencies and nongovernmental organizations this could prevent a future epidemic of sexually transmitted infections in Pakistan.

Key Words: Human immunodeficiency virus; Pakistan; Sex workers; Silent route; Youth

Core tip: Human immunodeficiency virus (HIV) is an emerging threat for rising generations in Pakistan. The prevalence of HIV is gradually increasing in different high risk populations due to the rapid increase of sexual activity among Pakistani youth. Increased sexual desperation among Pakistani youngsters has outranked the rest of the world. The rate of HIV spread in Pakistan is much greater than in any of the western countries, therefore adequate preventive measurements should be implemented as soon as possible, otherwise it will be too late.

TO THE EDITOR

Human immunodeficiency virus (HIV) is an emerging threat for rising generations in Pakistan. The prevalence of HIV is gradually increasing in different high risk populations due to rapid increase of sexual activity among Pakistani youth. Maximum viral spread and stable maintenance in the environment depends upon effectively penetrating protecting barriers[1]. Prevalence of sexually transmitted diseases was limited to certain areas but unfortunately, now, its prevalence has rapidly increased in different cities. Pakistan is an Islamic republic, where religion, law, culture and society strictly forbid sex outside marriage. Despite the recognition of sex outside marriage as a crime, commercial sex is being offered secretly in various brothels, kothikhana, client homes, rental houses near truck stops and market places, massage parlors and hotels. Strict punishments against sex outside marriage, if implemented by any nation, could prevent individuals from extra marital sexual activity.

We have identified silent routes stimulating sexual activity among teenaged Pakistanis. Most of the regular clients of sex workers write sexually attractive sentences about female sex workers on the doors of public toilets (in public places such as markets, parks, picnic places, hotels and bus stands) in order to promote sex in the younger generation. Contact details of female sex workers are randomly distributed in public washrooms. Sexually desperate youngsters, introduced to the opportunity, indulge in risky sexual activities which expose them to sexually transmitted infections like HIV and acquired immunodeficiency syndrome. At the moment, fortunately, the prevalence of HIV in the general population is very low. However, if unsafe sexual practices stimulated by this rapid advertisement route, were to be carried out by youngsters then this would probably generate an HIV epidemic in society which could create an extra burden on the economy. Another highly dangerous route of sexual advertisement is through Hijra sex workers. In Pakistan, the prevalence of HIV is highest among injecting drug users (IDUs) and Hijra sex workers. The greatest HIV prevalence (37.8%) was found in IDUs from different cities of Pakistan[2,3]. An extremely high HIV prevalence (27.6%) was observed in Hijra sex workers of Larkana Sindh, Pakistan[4]. Similarly another study conducted in Rawalpindi (the city adjoining Pakistan’s capital) reported a high prevalence of HIV (21.6%) among transgender men[5]. The rate of HIV spread in Pakistan is much higher than in any of the western countries, therefore adequate preventive measurements should be introduced as soon as it is possible.

Hijra is a distinct type of gender role which includes Khusras (true hermaphrodites), Zananas (crossdressers) and Narnbans (eunuchs)[6]. We have identified that the majority of Hijra sex workers have started promoting sexual activity in the younger generation by distributing various visiting cards among shop keepers and youth as sexual advertisements. Mobile numbers and visiting addresses are written on those cards. Sexually active people usually make a phone call and arrange a time and place for unsafe sexual activities. Hijra sex workers have also stepped into begging at various public sectors including bus stands, markets and traffic signals, where they not only earn money by begging but also promote sex work by contacting youths. Hijras usually flatter the physical beauty and power of their clients thus promoting sexual relationships. Most of the youngsters who indulge in risky sexual relationships are illiterate and have a poor understanding of sexually transmitted diseases and their consequences. Most of them lack awareness and knowledge, and are therefore unable to comprehend the seriousness of this issue.

In educational institutes such as schools and colleges, sex education is mostly avoided. Teachers are often reluctant to educate students with knowledge about awareness and prevention of sexually transmitted disease. If appropriate seminars were arranged for teenaged students this would be a positive step towards awareness and prevention of HIV and other sexually transmitted diseases. In order to reduce any future epidemic of sexually transmitted infections, harm reduction strategies must be implemented rather than intimidation by law enforcement agencies. The mysterious sex industry is based upon the principle of demand and supply. Sexually desperate unemployed youths, tourists, business men, public officials, migrant workers, truck drivers and traders with conspicuous wealth create a strong demand for sexual services. On the other hand, various social and economic factors like acute poverty, unemployment, limited knowledge and skills and the opportunity of a high income through sex, usually compel poor individuals towards offering sex. In such circumstances, suppressing measures via law enforcement agencies could further aggravate the spread of hidden risky behavior in society. It has been observed that Hijra sex workers have a strong wish to earn money by positive means but unfortunately our society does not accept them in either the private or public sector. The majority of Hijra sex workers are unable to earn money by positive means due to problems of sexual harassment from sexually active people. By arranging positive support for sex workers, via assistance from government sectors and nongovernmental organizations (NGOs) to earn an honorable livelihood, their risky sexual activities and behaviors can be reduced significantly.

Policy makers should not only provide wider opportunities for the dissemination of awareness and knowledge about risk factors associated with viral transmission among populations at risk; but also focus on identification of epidemiological patterns associated with sexually transmitted infections among various high risk populations in Pakistan. At the moment, an inadequate surveillance system for sexually transmitted infections exists with inadequate identification of subpopulations where deadly pathogens are secretly propagating. There is very little knowledge in the general and high risk populations about access to anti-retroviral therapy clinics. Expanded scientific research is also an important factor for successful surveillance of sexually transmitted infections. Among target populations, simple diagnostic tests against HIV could provide information regarding prevalence and trend of HIV infection. If the serum sub-samples are screened against other sexually transmitted infections (like hepatitis C virus and herpes simplex virus 2) after recording valuable basic demographic and behavioral data, this would help to identify behavior risk trends over time and aid surveillance. Another possible way towards harm reduction in Pakistan is by supporting community organizations and NGOs. The mysteries of complex HIV (and other sexually transmitted infection) dynamics could also be investigated using molecular epidemiology studies and mathematical modeling.