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Unequally yoked: Women highly vulnerable to HIV in Pakistan

Women are at high risk of contracting HIV from their husbands whose risky behaviour they cannot control or resist. Even female sex workers lack the power to negotiate for safe sex. Sehrish Shaban reports from Islamabad on how their lack of knowledge and empowerment ruined the lives of three women

Rubina has been living with HIV for six years now. The 28-year-old school teacher tested positive just one year after she was married. That's when she found out that her husband was infected, too.

"That day he told me everything," recalls Rubina. "I don't resent him for what he did. I just wish I'd known sooner so I could have protected myself."

Rubina's husband Akram used to work as a construction worker in Oman. He lived in a labour camp for five years with other migrant workers. He says his loneliness led him to engage in sex with female sex workers, and even with other men.

It was during this time that he contracted HIV. During a routine annual medical examination that migrant workers undergo in the Gulf region, which includes an HIV test, Akram tested positive for the virus. He was immediately deported to Pakistan.

"That was the most shameful day in my life," says Akram, lowering his head. "My earnings gave my family a better life here but, because of my disease, I not only had to give up everything for myself, I couldn't provide for them either."

Because of the social stigma attached to HIV-AIDS, Akram wasn't able to tell his family the truth. "I just kept the secret to myself and tried to lead as normal a life as possible while seeking treatment on the sly," he reveals.

Within a few months, Akram's family arranged his marriage with Rubina. For fear she might call off their wedding, Akram decided to keep his HIV infection a secret from her as well.

This is the situation for thousands of women across Pakistan, who are at high risk of contracting sexually transmitted diseases, including HIV, because of their lack of knowledge, awareness and a low social status that denies them their basic human rights.

"This power dynamic is the most basic form of violence against women," explains Dr Sikandar Sohani of the women's reproductive health NGO, Aahung.

Imbalance of power

"HIV and AIDS is a reproductive health issue and there is a tremendous amount of gender inequality in this field," says Dr Sohani. "There is a severe lack of awareness on safe sexual practices and, most of all, women are rarely in a position to negotiate safe sex because of the inherent economic and social power difference between the two sexes."

So severe is the situation that when Dr Sohani's team distributes free condoms to women, it also conducts violence awareness programmes as many women are frequently abused by their spouses for trying to play a decisive role in their sexual relationship.

"There are cases of women who are beaten by their husbands for suggesting the use of, or even for possessing, condoms and are then forced into having unprotected sex, thereby increasing their vulnerability to infections," he points out.

Drug use heightens vulnerability

Recent data shows the extent of women's vulnerability to HIV in Pakistan.

In March 2008, Punjab-based NGO, Nai Zindagi conducted a study on intravenous drug users (IDUs) in three major cities of the province. The study, titled 'Hidden Truth' revealed previously unrecognised risks and vulnerabilities of wives of injecting drug users.

Of the 125,000 street-based intravenous drug users in Pakistan, an estimated 51% are married. While HIV prevalence rates among IDUs ranged between 10% and 50% across Quetta, Faisalabad, Hyderabad, Karachi and Sargodha districts, research found that their spouses too were at very high risk.

In Faisalabad, 15% of the spouses of IDUs who were HIV-positive had already contracted the virus. In Sargodha, the prevalence amongst spouses of HIV-positive IDUs was recorded at 5%.

Approximately half of the women surveyed in the same study had never heard of HIV or AIDS and of those who claimed knowledge, up to 30% did not know how the virus is transmitted.

According to UNAIDS estimates, Pakistan has a low HIV prevalence (below 1%), but is classified as a high-risk country with concentrated epidemics emerging among certain vulnerable groups. This means that over 5% of a specific group is HIV-positive.

While vulnerable groups include male and female sex workers, transvestites, truck drivers, migrant workers and IDUs, the last is showing evidence of a concentrated epidemic. According to a study conducted by Nai Zindagi, in Sargodha, for example, a startling 51% of IDUs have tested positive for HIV.

Enabling change 

Forty-year-old Nadeem works as a community mobiliser for IDUs at the NGO, Pakistan Society, in Karachi. Nadeem's work day comprises of identifying injecting drug users in street corners of Karachi's low income neighbourhoods and motivating them to seek treatment. He does this by sharing his own story.

"I was a heroin addict for 15 years. I lived with my wife and three children in a modest flat in Nazimabad. I had a job as a television technician. We weren't rich but we were definitely comfortable and happy and, most of all, healthy. But then I started experimenting with drugs and before I knew it, I was not only spending all my money on my addiction, I came to a point where I was forcing my wife to work as a housemaid in people's homes to provide me with money to buy heroin."

Like most IDUs he counsels, Nadeem is HIV-positive. He says his drug habit made him abusive and he would frequently hit his wife -- mostly when they didn't have enough money for him to buy drugs. He is divorced from his wife now and lives in the Pakistan Society dormitory.

Says Dr Saleem Azam of Pakistan Society, "Many IDUs seek treatment only after they have been completely abandoned by their families. Their wives are usually the last ones to leave them because of the social stigma of divorce as well as lengthy divorce proceedings."

Wives also bear the brunt of their addicted and infected husbands' anger, fear and frustration, often expressed through violence.

"Domestic violence is extremely common amongst drug users," says Dr Azam. "Drug users, when intoxicated, flare up easily. They need money to buy drugs and their families are the first places they turn to. Many of them use their spouses or children to buy drugs because it is illegal and they get violent if their families refuse to comply. Some go as far as forcing their wives into prostitution to earn money."

Rape and HIV

With the epidemic spreading rapidly among IDUs in Pakistan, problems such as domestic violence are on the increase.

IDUs oftentimes turn to female sex workers. According to the Pakistan Society, approximately 5% of sex workers are HIV-positive. But Sarah Zaman of the NGO War Against Rape says these figures could easily be much higher because of the lack of access to HIV testing facilities for sex workers

"Rape and sexual violence is the most under-studied topic in Pakistan," says Zaman. "And because of the stigma attached to their trade, basic medical rights for female sex workers are largely ignored."

Shahla, who has been a sex worker for the last 10 years, says that while she is aware of her vulnerability to HIV, she has been in situations where one client picks her up but she is forced into sex with up to four or five men, one after the other, and oftentimes not paid.

"Most of my clients are alcoholics and drug addicts, and can be very abusive," Shahla says.

According to Nasreen Siddiqi, a programme officer at WAR, there is a strong correlation between violence against women and reproductive health. 

"This could be in the form of unwanted pregnancies, which rape victims often face, and unsafe abortions and sexually transmitted diseases, which include HIV."

The 2008 annual report published by the Human Rights Commission of Pakistan (HRCP) recorded 4,276 cases of women's rights abuses in 2007, which included 755 incidents of rape, 636 cases of honour killing, 736 cases of kidnappings and 143 attacks by burning.

HRCP emphasises in its report that these figures are grossly understated and only account for those incidents that were registered and in which the woman was found a victim.

Testing of rape victims

Rape victims in Pakistan are very vulnerable to HIV.

"Of the nine medico-legal centres in Karachi, only three are functional," says Siddiqui.

"Currently, even basic testing for rape cases is not carried out, and properly documented. HIV testing is not even part of the basic medico-legal examination for survivors. WAR and Aahung are working together to introduce it at these centres."

Meanwhile, Dr Sohani says that in the case of vulnerability of female sex workers and other women, the basic issue is the lack of awareness and education -- which is present equally in women and in health practitioners.

"Not only are women not aware of their basic rights and how they can protect themselves, but from my experience, even medical practitioners in both large government-run hospitals and neighbourhood medical clinics act in the most unprofessional way."

"Not only do they keep important information from patients," continues Dr Sohani, "they impose their values and biases when providing consultation. This fundamentally goes against internationally approved regulations set for health practitioners and it violates the patients' rights."

Nadeem's wife was lucky because she did not contract the HIV virus and she secured a divorce, although she did become a victim of domestic violence because of Nadeem's addiction and disease.

In Rubina's case, the deeply-rooted discrimination against women in Pakistan, which is both a cause and an effect of their low status in society and their consequent lack of knowledge and awareness, has made her a lifetime patient of an incurable disease.

And Shahla, for whom HIV is an occupational hazard and who cannot always protect herself from violence, lives in fear.  

(Sehrish Shaban is a features correspondent for Geo Television in Karachi)

Courtesy 2010 Features