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At Risk: Sex, HIV and the Community

By 31 December 2010 3 Comments


Once established among key men-who-have-sex-with-men communities and bisexual groups, HIV may spread rapidly to the general population, particularly women who are married to these men.

Around 15 years of age, clad in a dirty shalwar kameez, the boy walks around the park, zeroes in on a customer and having struck the deal, takes him to the filthy public toilet located on the premises. The ‘transaction’ takes a few minutes and the boy is out looking for his next client. He makes 30 to 50 rupees per job and in one day he can service several customers – and all of this unprotected sex.

Wearing a green shalwar kameez, kajal on her eyes, sporting bright pink thickly applied lipstick, painted nails and dangling earrings, Anmol, the transgender beggar in Jinnah Super Market greets me with a wide smile. “Baji aaj tu kuch dey do. Itney din baad ayee ho.” Anmol is not the only one of her ilk here. Over the past one year there has been a huge influx of transgender people (hijras) on the streets, in market places and in the public parks of all major cities, where they actively ply their trade – usually one that places them on the fringe of society.

“People perceive transgenders as sex workers, beggars or dancers. Unfortunately that isn’t too far from the truth. A lack of education and employment opportunities forces them to make their living in these ways,” says Sarah Gill, a transgender medical college student in Karachi, who is actively working for transgender peoples’ rights and to end the violence and discrimination faced by them. Gill is president of the Moorat Interactive Society (MIS) and general secretary of the Gender Interactive Alliance (GIA). “There is no acceptance for our community in society. We are a symbol of shame even for our blood relations,” says Gill, who launched the first helpline for transgender people in Pakistan and is working to bring them from being a marginalised community into the mainstream, by creating an enabling environment in which “they can be treated like, and have the same rights as, males in our society.”

“The term MSM has gained currency over the years. It basically refers to males who have sex with males, not men who have sex with men; the latter are just homosexuals. But MSMs includes transgenders who are not men. Actually, there are many who would fall into the MSM category. An MSM could also be a man who has had a sexual experience with another man once in his life, but is essentially heterosexual. By that definition, a majority of the men in the world would be considered MSMs,” says Qasim Iqbal.

HIV-positive since 1999, Iqbal has been working in the HIV sector in Pakistan since 2006. Educated in the US, he holds degrees in Fashion Design and Computer Engineering. Says Iqbal: “In the West when you talk about men who have sex with men, you can clearly identify the majority of them as being ‘gay’ or ‘bisexual.’ However, in our part of the world things are a bit different. Due to our cultural and religious values that result in a general inaccessibility of women, men satiate their urges with other men. Most of the time it is with peers, friends, classmates or neighbourhood kids; at times also with relatives. Sex is also quite common between clerics and their students. And often young waiters at roadside chai wala hotels are sexually abused by truckers passing by.”

“In the north,” adds Iqbal, “‘bachabazi’ is culturally accepted, where an affluent, older man has a young boy as an apprentice of sorts. Everybody knows there is a sexual relationship between the two. Even the wives know it, but look the other way. In the ‘civilised world’ we consider this sexual abuse, but often the boys invite it. They get taken care of and lead a life they would not otherwise. Whether they enjoy it or not, is moot.”

According to Iqbal, Pakistan has a large MSM population. However, he admits, “We have no idea how large, and it would be very difficult to estimate. The number of hijras can be roughly estimated, as they are recognisable. Explaining the difference between the two, Iqbal says that many MSMs would fall into the category of ‘gay boys,’ but unless they acknowledge they are gay, nobody can say so with any authority. By western definition they would not be considered gay, because eventually most of these men in Pakistan do get married to women and have families. However, there are large underground gay communities in the country, comprising such men, who meet and mingle at gay parties every month. And considering there are between 400 to 600 people at a party, you can imagine the numbers.”

Iqbal continues, “Condom use among MSMs is very rare, even within MSM sex workers. If you ask them why, they say, ‘We are not going to get pregnant.’” And they seem oblivious to the dangers of sexually transmitted infections (STIs), including HIV, which they have heard of as a la ilaj bemaari (incurable disease), but ponder over little. Thanks to the HIV ad campaign, a lot of stigma has been attached to the disease, so it has done more harm than help.

When the HIV infection, (called AIDS at that time) first erupted in the gay bath houses of San Francisco, the media started calling it the ‘gay cancer.’ And in the West, the gay community is still at highest risk of the disease. In Pakistan, since 1987, over 5,000 cases of HIV positive people have been reported to the National AIDS Control Programme, Ministry of Health (NACP). UNAIDS however, estimates that there may be 96,000 HIV-positive individuals in the country. Certainly, the number of HIV-positive people in Pakistan is burgeoning, prominent among them injection drug users and their sexual contacts, including male and transgender sex workers (MSWs), forming the core of the epidemic.

According to a study, sex work has a long tradition in Pakistan. Over the past three decades, this has transitioned from a predominantly brothel-based sex-work culture to a diverse and dispersed pattern where women, men and transgenders sell sex. Male sex workers (MSWs), hijras and a third of all female sex workers (FSWs) operate in public spaces such as parks or streets; the remaining FSWs operate out of homes or kotikhanas. Only about 400 work in brothels. The extrapolation of surveillance data in the study suggests there are around 125,000 FSWs and about 35,000 each of the MSW and transgender sex workers in the country. Mostly young (22 to 28 years), they debut early in the sex trade (the average age is 16-17 years for MSWs and hijras) and engage about 7-10 clients a week. Only about 20% (MSWs/hijras) of the sex workers report condom use with clients.

Dr Ayesha Khan, an infectious diseases specialist, states, “Transgenders are clearly at an increased risk of HIV and other STIs. Part of this is due to the fact that they engage in receptive anal sex, have multiple risk partners with the lowest condom use among the Most at Risk Populations (MARPs), and initiate sexual activity at an earlier age than male sex workers.  The use of lubricants is also rare among transgenders and that increases risk of transmission as well.”


Transgender sex workers in Pakistan are at an increased risk of HIV and other sexually transmitted diseases. Photo: AFP

Dr Khan’s study HIV Epidemic in Pakistan, indicates that “Anal intercourse transmits HIV more efficiently than vaginal intercourse, and once established among key MSM/bisexual groups, HIV may spread rapidly to the general population, particularly women who are married to these men.”

“Globally,” she adds, “transgenders have been more reluctant to use the healthcare system and face greater stigma and barriers to access, and Pakistan is no different.”

Reflecting on the Supreme Court ruling two years ago, that gave transgenders equal citizenship, community member Bindya Rana, 40, says, “We were so happy that we went to the Press Club to show our gratitude.” The ruling involved collecting data on the number of transgenders in the country. Thousands were registered, but when the hijras started demanding ID cards, the authorities said “we need to get you physically examined to determine whether you are male or female,” says Rana. “Why should we get medical check-ups? Why can’t we have just ‘transgender’ written in the sex column?” Rana asks.

Rana maintains that in Sindh alone there are around 16,000 to 17,000 transgenders. The Sindh government says the number is 2,547. She continues, “Hijras are victims of taunts and mockery. If we go to a health facility, the doctors ask questions such as, ‘Is your name Reema – Meera? Where do you feel the pain?’” Although she runs a boutique for a living, Rana spreads HIV awareness and prevention messages and gets transgenders tested for HIV/STIs. Says Rana, “It’s a pity that the world has moved on so much, but a segment of our society is so deprived – fighting for the most basic human rights. My struggle shall continue.”

“The case [pertaining to transgenders] remains pending before the Supreme Court; the orders relating to transgenders are basically in the nature of interim orders,” says Anees Jillani, advocate Supreme Court. He adds, “So far nothing has changed on the ground. If all the hijras are issued ID cards, it would help resolve some of their problems, like opening bank accounts. However, merely obtaining ID cards is not going to revolutionise their lives.”

According to Jillani, the only thing that can help this segment of the population is “to give them proper jobs. How many of us have the courage to hire hijras whether at home or for our business? These are social issues and the public needs to be made aware about them and to muster courage and help them.”

Religious edicts and social norms strongly forbid male to male or homosexual sex, deemed crimes punishable under the Pakistan Penal Code. Mufti Saifullah Khalid, Punjab Coordinator Inter-Religious Council for Health (IRCH) says, “Male to male sex is a ‘ghair fitri amal’ (unnatural act). Qaum-e-Loot was destroyed due to this very reason. The punishment for this act is very severe.” According to Khalid, “Men and women should be identified as male and female through their apparel. As far as hijras are concerned, in all aspects they are men, not women.” As a member of the IRCH, Khalid has conducted many workshops on awareness and given prevention messages on HIV and AIDS.

Says Qasim Iqbal, “An important challenge vis-à-vis reaching MARPs is that they are often marginalised, stigmatised and discriminated against. Partly as a result of this, and partly as a result of self-segregation, there is often a lack of information about these groups.” Iqbal recently started work on a project to prevent the spread of HIV among MSMs and transgenders in South Asia. The goal of the project, he says is “to reduce the impact of HIV and AIDS on men who have sex with men and in transgender populations (TGs). The project is being implemented in seven countries of South Asia. Of all these countries, Pakistan is getting the largest amount of money. Iqbal maintains, “This project will give the MSM community a sense of belonging, a place to turn to. We are not going to advertise it as an MSM clinic, but a ‘male health initiative.’ Sex workers will be hired as field workers.”

The truth is, in Pakistan, we are still largely in denial about HIV. This is a dangerous thing because AIDS affects not only the person who contracts it, but can affect entire families, or in some cases entire communities or villages.

Shivanand Khan, CEO Naz Foundation, believes, “Social exclusion needs to be addressed in ways that can encourage MSMs and transgenders to change patterns of risky behaviour that arise from low self-esteem and self-worth.” According to him, the populations most at risk comprise both injection drug users and MSMs/TGs, and they are the main drivers of the epidemics.

Talking to Newsline about the provision of health services for MSMs, he says, “While several NGOs are supposedly providing services, the quality of that service delivery is inadequate, top-down, and does not engage MSMs/TGs in service delivery. Ownership of the issue is thus very limited, and makes it very difficult to empower MSMs/TGs to shift from high-risk behaviour to low-risk behaviour. As a consequence, poor services lead to poor access, and therefore low numbers accessing services. To address low coverage requires an increase of funding for MSM and transgender HIV services.”

Given that HIV/AIDs is now a household term around the globe – even in many Muslim and developing nations, it is time Pakistan woke up and smelled the coffee. Denial will not make the problem go away.

To read about the gay community in Bombay, see the post “Men Seeking Men.”

This article was originally published in the December 2010 issue of Newsline under the headline, “No Sex Please, We’re Pakistani.”

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  • dsinla said:

    View the Award winning documentary “House of Numbers” to see why questions about this must be raised, and why deeper issues about HIV and AIDS need to be
    discussed. Lives are at risk. This is the first documentary ,with the worlds
    foremost authorities, that highlights the fundamental problems with HIV
    testing, science, and statistics, It sheds new light on a misunderstood
    phenomenon., for which there is still no cure.
    GO to http://bit.ly/fhUxaJ – bit.ly/gogKLZ to see the trailer of “House of Numbers”.

  • pozloves said:

    Due to the rise cases of HIV number, more awareness of HIV/AIDS is needed. One of my doctor friends who works on a largest online HIV dating site hivlover[dot]com said more than 300 new users join in this site everyday.

    The most bad thing is that about 2/3 of them are very sexy girls and living with HIV!! OMG, why so many young people are infected by HIV in USA? ??? Especially, most of them do not know the difference between HIV and AIDS. So bad…

    HIV is the virus that causes the disease AIDS. Although HIV causes AIDS, a person can be infected with HIV for many years before AIDS develops.

  • Apostle Shada Mishe said:


    THE IDEA that AMBUSH cures AIDS
    is being proven by the more than 400 individuals who have taken a dose of 60 ml three times daily for 21 days. The result is that AMBUSH ‘KILLS’ the virus by causing the protein envelope to rupture and the viral particles are discarded by the white blood cells. AMBUSH is able to ‘KILL’ the virus that are ‘hiding’ in the lymph system by its ‘natural radioactive’ properties. This process allows the body to ‘return to normal health’ with a corresponding immunity to that or those strains of the virus.

    What is AMBUSH ?
    AMBUSH is a radioactive isotope of uranium that is found in the ‘palm’ plant of which there are more than 3000 species. When ingested, AMBUSH causes the body temperature in the trunk area to rise to about 102 degrees when the individual is sleeping. The preparation takes four hours per batch, which is then given to the individuals for consumption 60 ml three times daily for 21 days. AMBUSH is a herbal preparation in this form but it contains an active ingredient which is a ‘NEW’ crystalline substance, a drug from the ‘palm plant’ similarly to ASPIRIN originating from the willow tree bark

    After 21 days on AMBUSH, ALL the individuals experienced a decrease in viral load to undetectable, an increase in cd4, increase in RBC, an improvement in general health such as more color to the face, decrease in Buffalo hump, an increase in gluteal muscles, a decrease to having no joint pains whereby individuals can bend to touch their toes, and walk up steps are but a few examples. There is also a dramatic increase in their sexual appetite beginning after the first week of therapy

    In any plant concoction such as percolated ‘tea’, there are 30-40,000 compounds, whi ch would take the scientific community twenty years to isolate one particular ingredient if they knew what they were looking for. The LORD GOD has given me seven steps to isolate the active ingredient, which is soft and metallic in nature and has a carbon- uranium-sulfur-(classified)-phentolamine configuration or structure. This is similar to Federick Kekule and the discovery of the benzene ring where he dreamt the structure.

    As an antiviral and ‘natural radioactivity’ producing agent, AMBUSH is also effective against leukemia, lupus and HPV. Here I am saying that I have ‘GIVEN’ AMBUSH in the same ‘strength’ and dosage to patients with leukemia, lupus and HPV. A 35 year old male with HIV found it difficult to impossible to urinate was put on ‘green tea’ and water while the doctors contemplated prostrate surgery. One of the doctors gave him my number , I sent him a supply of AMBUSH an d he has not been given any more ARV’s, since taking AMBUSH 18 months ago, is in ‘good’ health and has expressed a willingness to be examined by HIV investigators like many others who have taken AMBUSH.

    I have sent this ‘IDEA’ to most HIV research agencies, scientist of the field, universities, hospitals, clinics, politicians and news agencies to which it is REJECTED because the name of THE LORD GOD is mentioned. He has steered me scientifically through the processes such as which plant and how to produce the active ingredient. What are the odds of a Florida Pharmacist picking a plant would contain the CURE for HIV/AIDS ?
    I have never charged any of the people for their supply of AMBUSH but a life saving has been spent on the project with NO renumeration from any sources because AMBUSH falls outside the walls of modern medicine and research.


    My proposal is that I PROVE that AMBUSH CURES HIV/AIDS by giving it to a number of END-STAGE or DRUG-RESISTANT people and the scientific community watches their recovery. This proposal addresses the problem in that I have already outlaid the results to be obtained.

    This IDEA is unconventional in that the scientific community has rejected AMBUSH because I say it is GOD given. Secondly if I wrote it according to certain standards, then it might be peer reviewed. However, THE LORD GOD has also shown me that there are five enzyme systems associated with the virus, reverse transcriptase, protease, fusion and two more of which causes the virus to be AIRBOURNE. This means that without DIVINE intervention mankind and ALL warm- blooded mammals will be extinct in a number of years.

    The PROOF of what I am saying is found in scientific papers wherein it is found that when the protease cuts the viral strands, it cuts it at DIFFERENT lengths EVERY time, to which it should always be a valine at the end but is a different amino acid every time. This is why it is IMPOSSIBLE to produce a VACCINE.

    Since this is NOT a hypothesis but there are about 400 individuals who have taken AMBUSH, here lies a vast area in which to check, recheck and confirm that AMBUSH CURES AIDS. Let it be mentioned that during the HIV reproductive cycle, reverse transcriptase converts viral RNA into DNA compatible to human genetic materials. Thus the human DNA has been ‘hijacked’ and since each person has a DIFFERENT DNA, then the new viral copy is unique to that person which shows that each individual has a DIFFERENT STRAIN of the virus. Consider two HIV positive people swapping viral strains and increasing its complexity with multiple partners.
    It can also be proposed that they be revisited as proof that the strain or strains that they had were ‘killed’ at the time of taking AMBUSH considering that a person can catch as many different strains as there are people who are infected by HIV.
    I am also willing to work with the scientific community in identifying those individuals who took AMBUSH and wish to be identified with this process notwithstanding that some are stigmatized while others are jubilant,

    Once AMBUSH is verified as being able to accomplish that which is aforementioned then the next stage might be the natural and artificial synthesis of the substance.

    Finally, if this is accepted or not, believed or not, THE LORD GOD always wins and this is the heavenly truth to which AMBUSH was divinely given to mankind for the CURE of HIV/AIDS and it will be here forever.

    The WORLD is therefore COMPELLED to listen……sooner or later….your choice !!!!!

    Apostle Shada Mishe.

    Here is a video taped presentation that I gave at the Martin Luther King library in Washington