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July 31, 2003
A virus with no cure
The modes of transmission for Hepatitis B and C and HIV/AIDS are similar. Since the former has become a major health problem, there is clear indication that HIV/AIDS can also spread rapidly. Huma Khawar emphasizes the need for adequate measures to be implemented for creating awareness about the disease and its preventive measures, especially for its major victims who are under 25
On a global level the HIV infection has taken root in all continents including South Asia. At the end of 2002, the total number of people living with HIV/AIDS reached 42 million, 90 per cent of whom live in the developing world.
While overall prevalence rates in South Asia remain relatively low, the region’s large population means that a small rise in the prevalence rate will cause a huge increase in the number of people living with HIV/AIDS. This will have grave socio-economic impacts on already impoverished communities.
HIV/AIDS has an inherent link with poverty and poses a threat to development efforts in the region. It targets people at their most productive age — the population in the prime of their lives — thus adversely affecting socio-economic growth and development.
Throughout the world and in South Asia, young people are at the centre of the HIV/AIDS epidemic. More than half (58 per cent) of those newly infected with HIV today are below the age of 25.
Of the estimated foue million people living with HIV/AIDS in the South Asian region, more than a quarter are people below the age of 29. The human and economic implications of an HIV epidemic would be huge in the South Asian region, where an estimated 54 per cent of its population is below the age of 25.
Pakistan is a low prevalence but a high risk country due to increased levels of poverty, illiteracy, low spending on health and education, large numbers of internal and external migrants, a high proportion of adolescents and young adults, gender inequalities and silence and denial about risky behaviours.
As of September 2002, 1741 cases of HIV and 231 AIDS cases had been identified, though actual numbers are believed to be higher due to under-reporting and lack of an effective surveillance system.
Among the reported cases, the most common modes of transmission are heterosexual transmission (41 per cent), contaminated blood and blood products (17 per cent), followed by homosexual or bisexual transmission (four per cent), injected drug use (three per cent) and parent-to-child transmission (one per cent).
However, the mode of transmission for almost 34 per cent of the cases is not known. The World Health Organization (WHO) and UNAIDS estimates show that there are about 70,000 to 80,000 people living with HIV/AIDS; which is about 0.1 per cent of the total adult population.
Pakistan is in the phase where there are more reported cases of men than women, at a ratio of 7:1. But we should be vigilant of the fact that the infection can spread to affect women disproportionately.
Limited research indicates that prevalence of the HIV infection is one to two per cent in the population practicing risky behaviour — that is unsafe behaviour in sex workers, migrant workers, drug users, active male homosexuals, truck drivers on long routes, blood recipients, professional blood donors, sexually transmitted infections (STI) patients, prison inmates and seamen.
Although in the initial stages of the epidemic in the country, the response by the government of Pakistan was slow in view of the small number of cases, the first programme in HIV/AIDS began in 1987 with the support of WHO. But 1990 onwards the government started taking over the project, focusing on HIV/AIDS case detection approving the first PC1 at a cost of Rs 20 million.
The next project in 1994 adopted a more pragmatic agenda like blood screening and developing provincial programmes with a lot of emphasis placed on increasing awareness. In 1999 a situation analysis was done and gaps were identified.
The government, with the assistance of UNAIDS and inputs from all stakeholders, adopted the National Strategic Framework for HIV/AIDS. This has become the basis for a five-year, Enhanced HIV/AIDS Control Programme which has been launched at a cost of $47. 6 million.
There is general speculation that HIV/AIDS is a donor driven agenda and although hepatitis is a major public health problem, there is more focus on HIV/AIDS. “We need to clarify the fact that hepatitis, especially B and C share similar modes of transmission as HIV/AIDS. If hepatitis has emerged as a major health problem, it should put us on the alert that HIV can also reach devastating proportions,” says Dr Asma Bokhari, national manager, National AIDS Control Program.
“We address HIV in a comprehensive way by addressing the issue of sexually transmitted infections in totality. Like HIV, Hepatitis B and C are also STIs. If we are able to prevent STI transmission, by one effort we will be preventing other communicable infectious diseases in the country,” she continues to explain.
National AIDS Control Program (NACP) under the ministry of health has been working on the issue of HIV/AIDS for more than two decades. Dr Bokhari feels its time that NACP should have a higher profile. “From the issue of sustainability, it’s the government backing that is most important. Donors provide assistance but on a smaller scale and for a limited period only. Once that is withdrawn there is nothing left. Donors only come in when the government is committed,” she says.
“Since we are a Muslim country, donors initially had apprehensions that the Pakistan government might not work with the enthusiasm they expected. But we have worked with dedication and have proved ourselves,” she says referring to the Enhanced HIV/AIDS Control Program. “We have been fortunate the government has not been complaisant; they have been taking steps despite their own constraints and it is one of the top six priority programmes of the ministry of Health.”
While giving details Dr Bokhari says that besides working with police and uniformed personnel for their advocacy and sensitization, the programme includes blood screening of Hepatitis B and C, setting up of voluntary counselling and testing centres in different cities, strengthening care and support services for people living with HIV by setting up five centres where they will be provided Anti-Retro Viral drugs.
Low prevalence and under-reporting of the disease is due to the stigma attached to HIV/AIDS and the discrimination as a result are the factors for low visibility and thus the public at large does not consider it a health threat.
The fact that sexual activity is the main mode of transmission and that there is the threat of being branded promiscuous, means that people find it difficult to talk. As a result there is either silence or denial which makes it harder to address the problem and create awareness.
The HIV epidemic follows a vicious cycle perpetuated by a breakdown of social support systems, vulnerability of women and children and inability of health systems to cope with care of AIDS patients.
In each country, HIV/AIDS follows a typical pattern of transition from high-risk groups to men and then to the general population of women and children, affected by parent-to-child transmission.
Another major component of Enhanced HIV/AIDS Control Program is to provide very defined service delivery packages focusing on behaviour change, communication and advocacy and a comprehensive surveillance system.
“We call ourselves low prevalence because we don’t know. We didn’t have a very comprehensive surveillance system in place. The situation in Larkana shows that we do not know a lot of things,” says Dr Bukhari, referring to the recent incident in Larkana and Hyderabad where after a blood screening of some 176 drug addicts, 38 were confirmed to be HIV positive.
UNAIDS, however, is of the opinion that strategies to deal with such emergency situations need to be formulated in consultation with all the stakeholders. “UNAIDS is trying to explore the possibilities to invite regional and international experts in these consultations and discussions,” says Dr Furrukh Mahmood, programme officer at UNAIDS in Islamabad.
A UNAIDS report says about 2.1 million young people aged between 15 to 24 are living with HIV in Asia Pacific. “Young people are vulnerable to HIV due to their risky sexual behaviours or substance abuse and they lack access to HIV information and prevention services. Even now in so many Asian countries, they have still not heard of HIV/AIDS,” says Imran Rizvi, member board of UNAIDS, representing NGOs in Asia and the Pacific.
According to Laura Fragiacomom, working with youth awareness at UNICEF, 50 per cent of all new global infections occur in young people. She feels it is important that children enter adolescence with sufficient knowledge and skills to make the right choices and live free of HIV. “In Pakistan, where more than half of the population is under 25, investing in this segment means a secure future,” she says.
Local and international NGOs have played a significant role in the fight against HIV/AIDS as part of a development process in Pakistan, as they have in other countries, partly because of their close involvement with the communities they serve. Currently, at least 72 NGOs are focusing on HIV/AIDS related activities.
HIV/AIDS is a multi-sectoral problem. It is a development issue and not just a health issue. No one is immune because of his or her race, nationality or religion. It is a lifetime infection and to date has no cure. The cost of care is enormous more so than investment for prevention. The only way to avoid acquiring the HIV infection is awareness and adopting precautionary measures. If we act now and take timely measures, unlike our neighbours in India and Nepal, we can avoid a major epidemic.
Alarming statistics
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According to a situation and Response Analysis on HIV/AIDS in Pakistan conducted by the Ministry of Health and UNAIDS, in May 2000, Pakistan has a relatively high rate of external migrations. (In January 2003, there were 31,77,383 documented Pakistanis working abroad, according to the Overseas Pakistanis Foundation (OPF), which include both skilled and unskilled labour, technicians and professionals.What is frightening is, that according to the report, ‘a substantial number of the reported HIV infections in Pakistan have occurred among men who have worked in other countries’. A majority of these were men who had gone for economic benefit and had been away for long periods leaving behind their wives and families.
But the scenario gets grimmer because the report points out that ‘the very people who are most likely to become infected with HIV/AIDS in Pakistan are the younger members of society, the group that represents the most economically productive segment of the country’s population’.
If we look at the cross section of these migrant men, the profile that emerges shows that most are young. These young people lack information and awareness about reproductive health in general and about STIs and HIV/AIDS in particular. The reasons are multifold with social taboos that inhibit open discussion of issues ‘related to sex and reproductive health, opportunities to gain accurate information about such issues and to learn skills with which to protect oneself from infection’.
In the case of migrants, both external and internal, factors such as an unfamiliar setting, feeling of loneliness, isolation, an expendable income as well as a feeling of freedom of being away from home and family, can all contribute to engaging in high-risk behaviour.
In 1987, soon after the diagnosis of the first HIV/AIDS case in the country, the Ministry of Health established the Federal Committee on AIDS (FCA) and, in 1988, NAP was launched based at the National Institute of Health.
It, however, remained dormant till 1990 when the first government-funded programme plan for the NAP was developed and budgeted for a period of three years. But as Dr Sharaf Ali Shah, director of Sindh AIDS Control Programme, remarks: “The government is committed but is beset with so many problems, deficient resources being paramount, that the work is still not visible.” The programme faces many impediments “with denial being a major barrier”.
According to Mushtaq Ahmed, general manager (Sindh) Overseas Pakistanis Foundation, around 80 to 90 per cent of HIV/AIDS cases are of migrant workers. “It is imperative that host countries pitch in if we are to control the spread of HIV/AIDS further. By and large, when the illiterate migrant is sent back, he has no idea that it is because of him having contracted HIV/AIDS. He then becomes a carrier and comes home and unknowingly spreads it within his family. I feel that the migrant should be allowed to continue work, as it is not such a disease that his health debilitates him immediately after diagnosis. Once his medical test shows that he is HIV positive and the host country decides that they have no choice but to send him back home, he should be counselled and told how he can prevent its spread further.”
Dr Farrukh M. Ansari, senior programme officer at UNAIDS is of the opinion that the government would do well to muster support from the NGOs, “If we can somehow liaise with NGOs working on this issue in the host countries, maybe such a collaboration can prove fruitful.” At another level, “If we can have people from NGOs and train them to become counsellors and have a job of just holding pre-departure briefings on a one-to-one basis at the designated medical centres, from where these migrants get their medical tests done, we can overcome some of the problems.”
Of late the NACP, in collaboration with UNAIDS, has been having awareness raising seminars with various organizations and agencies involved with migrant workers like recruitment agencies, travel agents, OPF, Overseas Employment Corporation, Bureau of Emigration and Overseas Employment, etc and briefing them about the disease, the social, emotional and economic vulnerabilities of migrants and how they can help assist the government with spreading awareness.
These people have recommended ‘passports with stickers giving information about HIV/AIDS and its prevention’, ‘airline tickets that have a brief explanation of the syndrome’, and ‘holding seminars and briefings in regional languages’ etc.
While there is a lot of emphasis on pre-departure briefings, Mushtaq Ahmed of OPF has a point when he says from his experience that, “such briefing sessions are not very useful. Very few people can make it to these centres as it is not possible for the recruiting agents to call their clients a day in advance of their departure, it also involves cost of their stay and since most people may not understand a lecture given by a technical person or in their native language, holding of such briefings are an exercise in futility.”— Zofeen T. Ebrahim
The role of the media
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The media can play a catalytic role in the fight against HIV/AIDS by reaching the homes of millions of people in Pakistan, and disseminating life saving information.Pakistan — under the National AIDS Control Program — was the first Muslim country to start a media campaign as early as 1987, keeping in mind the local socio-cultural sensitivity. By 1994, an electronic and print media campaign was one of the major components of the programme consuming 50 per cent of the programme’s budget.
“The communication strategy has evolved over time. TV messages like, ‘Be faithful and limit your life to one partner’ have been replaced with messages like, ‘Take care in all intimate relationships’,” says Qamar-ul Islam Siddiqui, advisor, Health Education for NACP.
“The media is key for spreading awareness and changing attitudes and behaviour of people. Mass education can dispel misconceptions and create a favourable environment for HIV/AIDS prevention. It also seeks community support and endorsement,” says Johannes Lokollo, chairperson of the UNAIDS Theme Group.
According to a survey conducted on mass media messages, people have expressed the need for explicit messages. It’s important that there is an agreement on appropriate wording and phrasing in our socio-cultural context. Misconceptions lead to suspicions and rumours. For example, the word condom can still not be aired even for family planning messages. These barriers need to be broken to reach each household effectively.
Following are some of the findings/views of the public on the role of the media in creating awareness on HIV/AIDS:
Journalists reporting on HIV/AIDS should understand medical terms associated with it to make their reports accurate.
The media can play a leading role in breaking the silence around existing taboos in a socially responsible manner. They can play a major role in relaying information and appropriate messages between the government, civil society and the general public.
The media should portray HIV/AIDS related issues in a holistic and sensitive manner and begin cultivating a network and resource base of media professionals committed to this task.
The media should try not to stigmatize and discriminate against infected and affected people, highlight vulnerability factors that put people at risk for infection, generate motivation rather than hopelessness, move from a health emphasis to an understanding of the development and human rights implications.
The media should explore constraints and opportunities in breaking the silence on HIV/AIDS and adequately address prevention and care in the country from it’s perspective.
The media can draw inspiration from the injunctions of the Holy Quran that clearly preach responsible behaviour, communal well-being and support, faithfulness to one’s life partner and abstinence from all forms of addiction.
All those concerned with TV and radio can be the frontline force for information dissemination, creating public opinion and influencing attitudes and behaviours.
Through a participatory exercise, the media can identify how the government and other development partners working in the field can best provide them support in addressing these challenges.— H.K.
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