By Muhammad Fareed
The International AIDS Candlelight Memorial, a program of the Global Health Council, is among the world’s oldest movements by civil society for HIV/AIDS remembrance, awareness and community action. Started in 1983, the historic Candlelight Memorial takes place every year on third Sunday in May. It is led by some 1,200 volunteer Candlelight Coordinators in 119 countries who host vigils for their communities. The theme for 2008 is “Never give up, Never forget”
The Candlelight Memorial is also more than just a memorial. It is an opportunity to educate about AIDS, advocate for policy change, foster partnerships and community dialogue, and improve skills for community mobilization. With 33 million people estimated to be infected worldwide, the Candlelight serves as an important uniting intervention among civil society and their governments, breaking down social barriers, and giving hope to future generations.
The Candlelight Memorial is committed to ending HIV/AIDS by raising awareness and advocating for the advancement of effective policies at all levels. The program has identified the following key issue areas as its platform around which it cultivates community advocacy through its events and activities:
Candlelight Advocacy Platform
Reducing Stigma & Discrimination
Communities around the world affected by the HIV/AIDS pandemic, particularly people living with the disease and other marginalized groups, often face debilitating social stigma and discrimination simply because of their association with the virus. The Candlelight Memorial urges leaders to fight discrimination through protecting the rights of affected groups and individuals, and fostering an inclusive human environment of both support and opportunity.
Ensuring Access to Treatment, Prevention & Care
Poor or marginalized communities have little access to basic AIDS services. The Candlelight Memorial urges leaders to ensure communities equal access to treatment (such as testing and anti-retroviral therapy); evidence-based prevention (such as education and condoms); and care and support (such as counseling and hospice). This requires meeting the needs of orphans and vulnerable children, strengthening public health systems, and vaccine development.
Increasing Resources for HIV/AIDS, Malaria, Tuberculosis and other Related Issues
The needs of communities affected by HIV/AIDS by far outpace the current resources allocated to meet them. The Candlelight Memorial urges leaders to fulfill their commitments to adequately address the scope and depth of AIDS, including other burdens accompanying or enhancing its spread such as TB, Malaria, Sexually Transmitted Diseases and opportunistic infections, and other contributing social and economic challenges.
Promoting Greater Involvement by Affected Communities
Affected communities by HIV/AIDS are often neglected in the decision-making processes that aim to assist them in the first place. The Candlelight Memorial urges leaders to incorporate the voice of affected communities in the formulation of policy, as well as in the design and implementation of programs. Their experience and opinions are essential to the global dialogue about the disease. This includes promoting the empowerment of women and youth.
Factors for Vulnerability to AIDS
High risk behaviour among Injecting Drug Users (IDUs):
IDUs are at a high risk of acquiring HIV and other blood borne infections because they often resort to unsafe practices such as needle and syringe sharing. Pakistan is a major transit and consumer country for opiates from neighbouring Afghanistan, the world’s largest producer of opium.
As far back in 1999 the United Nations Office of Drugs and Crime had conducted studies in Lahore that revealed that addicts were switching methods of drug ingestion – moving from smoking or “sniffing” or inhaling to injecting polydrug cocktails. This, the UNODC had warned could lead to increase in HIV as needle sharing and use of non-sterile equipment was common .
The number of drug dependents in Pakistan is currently estimated to be about 500,000, of whom an estimated 60,000 inject drugs. It is also unlikely that outbreaks which have been witnessed in 2004 are likely to be contained or limited to one area. Many of these injectors move from city to city (21% of the Karachi users had also injected in other cities) and a very high proportion of them use non-sterile injecting equipment (48% in Karachi had done so in the week before the survey was conducted). Risk behaviour in Lahore is even higher: 82% of injectors had used non-sterile syringes in the previous week, 35% did so all the time, and 51% had injected in another city in the previous year, according to Pakistan’s Ministry of Health. An HIV epidemic among injecting drug users was reported in 2004 in Pakistan’s Sindh province, in the town of Larkana where almost 10% of drug injectors tested HIV-positive. Knowledge of HIV among injectors (and sex workers) is extremely low. In Karachi, Pakistan’s main trading city, more than one quarter had never heard of AIDS and many did not know that using non-sterile injecting equipment could result in infecting them with HIV, according to Ministry of Health’s findings.
Unsafe Practices among Sex Workers :
Female sex workers (FSWs) and female migrant workers are often exploited and abused, and have little recourse due to their low social status and limitations in legal protection. Commercial sex is prevalent in major cities and on truck routes. Behavioral and mapping studies in three large cities found a sex workers population of 100,000 with limited understanding of safe sexual practices. Furthermore, sex workers often lack the power to negotiate safe sex or seek treatment for STIs.
Recent findings indicate that although HIV prevalence remains below 1 percent, FSWs and their clients report low condom use. Less than half the FSWs in Lahore and about a quarter in Karachi had used condom with their last regular client. Meanwhile, in Karachi, one in five sex workers cannot recognize a condom, and three-quarters do not know that condoms prevent HIV (in fact, one third have never heard of AIDS), reports UNIADS Update 2005. It is therefore little wonder that only 2% of female sex workers said they used condoms with all their clients in the previous week.
In addition to the lack of knowledge and low use of condoms, there is a high degree of sexual interaction between drug injectors and sex workers. Ministry of Health findings reveal that over 20% of female sex workers in Karachi and Lahore had sold sex to injecting drug users and condom use was very low during those encounters. Among injecting drug users in Lahore, almost half had had sex with a regular partner in the previous year, one third had paid for sex with a woman (11% used a condom consistently) and almost one quarter had paid for sex with a man (5% used a condom consistently). Male sex workers also trade sex with injectors, 20% of whom reported buying anal sex in the previous year (and only 3% of them used a condom consistently).
Men who have Sex with Men (MSM):
While there is little documentation about the extent to which men engage in sexual activity with other men in Pakistan, the limited evidence available suggests that such activity does occur throughout the country. Anecdotal evidence indicates that sexual activity between men occurs relatively frequently in boys’ hostels and jails; additionally, research suggests that sex between men is often practiced among long distance truck drivers. Finally, there is a small but highly mobile population of transvestites, transsexuals and eunuchs known as the hijra, who are known to engage in unsafe sexual practices. Lahore had an estimated 38,000 MSM in 2002. The MSM community is heterogeneous and includes Hijras (biological males who are usually fully castrated), Zenanas (transvestities who usually dress as women) and masseurs. Many sell sex and have multiple sexual partners.
Inadequate Blood Transfusion Screening and High Level of Professional Donors:
The collection and transfusion of blood and blood products, the use and re-use of unsterilised medical instruments (especially needles and syringes) and the generally low level of attention to standard infection control procedures are important potential avenues for the spread of HIV in Pakistan’s general population. The indiscriminate use of blood transfusions and of needles in both the formal and informal health sectors is common. In addition, standard procedures for infection control in health care settings are often not strictly followed. A relatively high prevalence of both hepatitis B and C infection in the general population suggests that unsafe blood transfusion practices and poor infection control are likely to make a significant contribution to the further rapid spread of these infections and of HIV/AIDS among the general population. It is estimated that 40 percent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. In 1998, the AIDS Surveillance Center in Karachi conducted a study of professional blood donors. people who are typically very poor, often drug users, who give blood for money. The study found that 20 percent were infected with Hepatitis C, 10 percent with Hepatitis B, and 1 percent with HIV. About 20 percent of the blood transfused comes from professional donors.
Large Numbers of Migrants and Refugees
Migration can create conditions in which people become vulnerable to infection. It is commonplace in Pakistan for men to travel away from their homes to find work, either within the country or abroad. This separation from their spouses, families and communities can result in loneliness and isolation, and can lead migrants to engage in social and sexual practices that put them at risk of exposure to HIV. In addition, though there is virtually no documentation of the HIV/AIDS-related risks experienced by the large numbers of refugees in Pakistan, global experience suggests that this population may be highly vulnerable to HIV. Large numbers of workers leave their villages to seek work in larger cities, in the armed forces, or on industrial sites. A significant number (around 4 million) are employed overseas. Away from their homes for extended periods of time, they become exposed to unprotected sex and are at risk for HIV/AIDS.
Unsafe Medical Injection Practices: Pakistan has a high rate of medical injections around 4.5 per capita per year. Studies indicate that 94 percent of injections are administered with used injection equipment. Use of unsterilized needles at medical facilities is also widespread. According to WHO estimates, unsafe injections account for 62 percent of Hepatitis B, 84 percent of Hepatitis C, and 3 percent of new HIV cases.
Sexually Transmitted Infections (STIs)
Personal awareness and knowledge of reproductive health issues is limited, and often erroneous, among the men and women of Pakistan due in part to the generally low levels of education, and also due to their limited access to effective reproductive health services. Men and women alike are often unaware of the differences between reproductive and sexual “health” and reproductive and sexual “disease”. When they do become aware of a possible sexual or reproductive problem, they often seek care from traditional healers (hakims) or from one of the many unregulated “sex clinics” in the informal health sector. In addition, it is estimated that only 60% of the country’s population have access to the formal health care system and many (through personal preference or necessity) resort to the use of hakims, or traditional healers. It is not uncommon for clinics in villages to be operated by self-described “doctors” who may actually have little or no formal medical training. This reliance upon unqualified practitioners may compound the risk of further infection due to their lack of knowledge and the possibility of inadequate infection control during their therapeutic procedures. Health care professionals generally believe, however, that the incidence of STIs in Pakistan may be increasing due to the relatively widespread presence of risk behaviors.
The 2004 STI survey found that 4% of MSMs in Karachi were infected with HIV, as were 2 % of the Hijras in the city. Syphillis rates were also high with 38% of MSMs and 60 % of Hijras in Karachi infected with the disease. As a consequence, sexually transmitted infections rates are high: in Karachi, 18% of injectors were found to be infected with syphilis, as were 36% of male sex workers and 60% of Hijras or transgendered persons.
Gender Inequalities may also play a facilitating role in the further spread of HIV/AIDS in Pakistan. Pakistani women in general have lower socio-economic status, less mobility and less decision-making power than do men, all of which contributes to their HIV vulnerability. For example, because of gender disparities in educational enrolment, the female literacy rate in Pakistan is much lower than that of males (35% for women as compared to 59% for men according to the Government of Pakistan’s Economic Survey). While illiteracy presents an obstacle for HIV/AIDS prevention efforts in general, it is much harder to reach women than men with information about how they can protect themselves from HIV infection. Women also are under-represented in the formal labour force, which, combined with their lower literacy rate and educational levels, reinforces their economic and social dependency on men. Additionally, restrictions on mobility often make it difficult for women to obtain access to health and social services, including access to basic reproductive health care. Finally, in situations where their decision-making power is restricted, it is unlikely that all women are equipped with the skills necessary to negotiate with their partners for safer sexual practices.
The National Response
In 1988, shortly after the diagnosis of the first HIV/AIDS cases in the country, the Ministry of Health established the National AIDS Control Programme (NACP), based at Pakistan’s National Institute of Health . In its early stages, the programme was focused on diagnosis of cases that came to hospitals, but progressively began to shift toward a community focus. Its objectives are the prevention of HIV transmission, safe blood transfusions, reduction of STI transmission, establishment of surveillance, training of health staff, research and behavioral studies, and development of program management. The NACP has been included as part of the government’s general health program, with support from various external donors. As the government has indicated in the recent scaling up of its response to HIV/AIDS, more needs to be done. A special focus on reducing the exposure of high-risk groups is urgently required. Improving skills, building capacities, strengthening advocacy, and increasing participation is needed not only in the area of health, but in several sectors, including education, labor, law and order, etc.
Provincial implementation units for AIDS control and safe blood use have been established in four provinces and two federally administered areas. A comprehensive awareness strategy has been implemented and 39 countrywide surveillance and diagnosis centers have been established. The Government has in collaboration with UNAIDS and its cosponsors developed a “Strategic Framework” for the next five years. This framework has identified nine priority areas which include: expanded response, vulnerable and high-risk groups, youth surveillance and research, care and support, general awareness, blood and blood product safety, STIs and infection control.