August 2008, Volume 58, Issue 8

Editorial

Men who have sex with men: New emerging threat of HIV/AIDS spread in

Arshad Altaf  ( Canada-Pakistan HIV/AIDS Surveillance Project of Canadian International Development Agency Karachi & Islamabad )
Sohail Abbas  ( Canada-Pakistan HIV/AIDS Surveillance Project of Canadian International Development Agency Karachi & Islamabad )
Hasan Abbas Zaheer  ( National AIDS Control Programme, Ministry of Health, Government of Pakistan, Islamabad )

Pakistan has progressed from low to a concentrated level of human immunodeficiency virus (HIV) epidemic primarily because of consistently high prevalence of infection among injection drug users (IDUs).  Following the first outbreak in this group in 20031 the prevalence has steadily increased and reached as high as 31% in 2007 in Karachi.2 While there are harm reduction programmes with needle/syringe exchange and other services there are still no drug (methadone/buperonorphine) substitution programmes in the country. 

Men Who Have Sex with Men (MSM) is a term created to include MSM who do not identify as gay or bisexual.3 Among them commercial sex workers including male sex workers (MSWs) are those men who indulge in sexual activity with another man for money or financial benefits.  Similarly transvestites or hijra sex workers (HSWs) are those who identify themselves as hijras and indulge in sexual activity with another man for money or financial benefits.  Findings of subsequent rounds of second generation surveillance conducted in the country suggest that these two groups are emerging as the second highest risk group in Pakistan.  Their numbers in four cities of Sindh (Karachi, Hyderbad, Sukkur and Larkana) are estimated to be around 16,000 (MSWs 7,700 and HSWs 8,300).2  The prevalence of HIV infection has been on the rise among them.  In 2004-5 the Karachi Pilot study found prevalence of HIV infection 7% (14/200)4 and in round 1 of surveillance in 2005-6 in Karachi the infection was found to be 4% (8/200) among MSWs and 1.5% (3/200) among HSWs.5 In 2006-7 the infection rates had risen to 7.5% in Karachi.  In other cities of Sindh for e.g. in Larkana it was found to be 2.5% among MSWs and 14% among HSWs; in Hyderabad 2% (4/200) HSWs were HIV positive.2 Previous studies have also documented their risk factors in 1999.6

In view of the emerging threat Sindh AIDS Control Programme started service delivery packages for prevention and control of HIV infection for MSM in Karachi, Hyderabad and Sukkur in 2006.  The clientele of MSW/HSW range from unmarried or married bisexual men, migrant workers and long distance truck drivers living away from home.  Condom use among MSW and HSW in paid commercial sex in Sindh has also been quite low (6.7%)2 while reviewed literature suggest that correct and consistent condom use reduces the risk of sexual transmission of HIV infection by 80-90% and efficacy that exceeds those reported for many of the world's standard vaccines.7,8

It is notable that at least 5-10 percent of all HIV cases worldwide are attributable to sexual transmission between men.  In countries in the Asia-Pacific region, HIV prevalence among MSM ranges from 3-17 % (5 to 15 times higher than overall HIV prevalence).9 Prevention investment targeting MSM has been effective in reducing risk behaviours among MSM.10

The experience of working and interacting with this high risk group in Pakistan suggest that it is relatively easier to work with hijras sex workers compared to male sex workers.  There are some key hurdles which require mentioning here:

1. Hijras are identifiable and relatively easier to work with however, their leader commonly called guru has to be involved in the process. 

2. Because of the stigma attached to MSM it is quite difficult to reach and educate them as they are a hidden group.  

3. The society as a whole in Pakistan is not willing to accept the existence of MSM/MSWs and fear of harassment and violence causes difficulty in identifying them. 

Prudent measures with appropriate coverage programmes increasing health awareness and promoting condom and lubricant use are needed to improve risky behaviours.  The challenge is to achieve the desired behaviour change and practices which can help reduce the transmission of HIV among this vulnerable group. 

References

1. Shah SA, Altaf A, Mujeeb SA, Memon A. An outbreak of HIV infection among injection drug users in a small town in Pakistan: potential for national implications. Int J STD AIDS. 2004; 15: 209.
2. HIV Second Generation Surveillance in Pakistan, National Report Round 2.  In National AIDS Control Programme Ministry of Health, Government of Pakistan and Canada-Pakistan HIV/AIDS Surveillance Project; 2006-7. 
3. Gay Men's Health Crisis:  http://gmhc.org/health/glossary3.html. (Accessed on 29th March 2008).
4. Pilot Study in Karachi & Rawalpindi: Integrated Behavioral and Biological Surveillance. In National AIDS Control Programme Ministry of Health, Government of Pakistan and Canada-Pakistan HIV/AIDS Surveillance Project; 2004.
5. HIV Second Generation Surveillance in Pakistan, National Report Round 1.  In National AIDS Control Programme Ministry of Health, Government of Pakistan and Canada-Pakistan HIV/AIDS Surveillance Project; 2005-6. 
6. Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon A. Seroprevalence of HIV, HBV, and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan. Int J STD AIDS. 1999; 10: 300-4.
7. Halperin DT, Epstein H.  Concurrent sexual partnerships help to explain Africa's high HIV prevalence: implications for prevention.  The Lancet 2004; 364:4-6. 
8. Cohen DA, Farley TA.  Social marketing of condoms is great, but we need more free condoms.  The Lancet 2004; 364:13-14. 
9. Van Greinsven, F. Epidemiology of HIV and STI in MSM in the Greater Mekong Region. Presented at "Strategizing Interventions among MSM in the Greater Mekong Sub-region." Strategy Report of the CDC-GAP/USAID-RDM/FHI-APD Workshop, February 28-March 2, 2005, Bangkok, Thailand, p.8.) 
10. Herbst JH, Sherba RT, Crepaz N, Deluca JB, Zohrabyan L, Stall RD, Lyles CM; HIV/AIDS Prevention Research Synthesis Team. A meta-analytic review of HIV behavioral interventions for reducing sexual risk behavior of men who have sex with men. J Acquir Immune Defic Syndr. 2005; 39: 228-41.

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