Preventing an HIV/AIDS Epidemic One Peer at a Time

By Aisha Mohammed
Edited by Chen Lou
Pakistani eunuchs light candles during a rally to mark World AIDS Day in Karachi, Pakistan on Tuesday, Dec. 1, 2009. Photo from: AP.

Several years ago, Tanvir Ahmed’s wife found out she was HIV positive. Later, Ahmed and his three children, ages 4, 5, and 7, were also diagnosed as positive. Ahmed resides in Jalal Pur Jattan, a rural community in Pakistan, where stigma against HIV/AIDS is widespread and exists even among healthcare providers. “When my extended family members found out us, they abandoned us. This is common,” said Ahmed.

Ahmed suspects that his wife contracted the virus when she visited a “quack” doctor and received an injection with a used needle. Although the HIV incidence in Pakistan is low as compared to other Asian countries, Jalal Pur Jattan has an estimated 200 known cases among its population of nearly 100,000 residents. The village is also home to a large migrant worker population and a joint study conducted by UNAIDS and Karachi’s Aga Khan University in 2007 predicted that HIV infections among migrant workers may cause an epidemic in communities like Jalal Pur Jattan.

Mandatory testing for HIV and other infectious diseases is a requirement for obtaining and renewing work visas in the Gulf States. Approximately 150,000 Pakistanis migrate each year and those who test positive are deported with no counseling or treatment.

In 2008, the U.A.E. government deported 1,518 workers infected with HIV, hepatitis B and C, and tuberculosis, according to a U.S. State Department report. Many return home and end up either infecting their spouses, or engaging in high-risk sexual behavior, which contributes to spreading infections in their communities. Host countries do not notify sending countries and only inform workers that they are “unfit” to work. A lifetime ban prevents workers from returning, even though many have invested $700 to $1,800 USD through loans and land sales to finance their trips abroad. An average worker earns approximately $80 USD per month in Pakistan and these debts can take years to pay off.

Under pressure to pay off debts and afraid of stigma, many former workers wait to seek treatment until they can no longer ignore the symptoms. “Workers disguise the fact that they have a disease because of the stigma. They seek treatment after they have spent all their savings and are too weak to work,” said Asher Bhatti, Programme Officer at the New Light AIDS Control Society in Lahore.

In the last 18 months, the number of registered HIV cases has doubled but this could be due to recent outreach efforts and not an increase in new cases, said Dr. Hasan Zaheer, director of the National AIDS Control Programme (NACP). The NACP currently has an estimated 4,000 cases on record, which is a fraction of the 96,000 people that the UN estimates are living with HIV in Pakistan.

To find ways to curb a countrywide epidemic, the NACP organized a meeting in May 2009 at the World Health Assembly in Geneva. Representatives from Pakistan, China, Thailand, Afghanistan, Bangladesh and Nepal attended the meeting, along with senior officials from global health and labor organizations. “Due to the sensitivity of the issue, we decided to engage in dialogue with the receiving countries on a one-to-one basis,” said Dr. Zaheer.

AIDS support workers and family members comfort a final stage AIDS patient in 2006 in sialkot, Pakistan. Photo from: Life.

Aside from dialogue, Pakistani government officials and NGOs are also trying to raise awareness of HIV/AIDS among migrant workers before they leave the country. The Pakistani Village Development Programme (PVDP) established a pilot program at the Peshawar airport in 2008 in collaboration with Family Health International. PVDP staff conducted focus groups with migrant workers and seminars with the cabin crew of airlines. They also provided counseling and referral services and informational materials to deportees.

“The problem with printed materials is that most workers are illiterate, and they are usually in a hurry and anxious when they are leaving,” said Dr. Muhammad Saleem, Monitoring and Evaluation Adviser for UNAIDS in Pakistan. A UNAIDS study in 2007 found that the most effective intervention points are not airports, but pre-departure mandatory testing labs in Pakistan, and workers’ hostels and medical testing centers in host countries.

With the exception of Dubai, the Gulf States require mandatory testing before travel and workers usually spend a whole day at laboratories with no awareness of what the tests are for. The labs, operated by Gulf State authorities, are not required to provide any counseling, and the Pakistani government is planning to establish volunteer counseling and treatment at testing sites. Along with the labs, hostels are also a good venue for intervention because of the large concentration of workers in one place, said Saleem. “Ten to fifteen people live in one room and we are planning to do targeted education and condom distribution in hostels,” he said.

Another important component is identifying and training workers for peer-to-peer education. The Pakistan Village Development Programme conducted an informal study in the U.A.E. and found that the majority of migrant workers did not know about safe sex practices or how HIV/AIDS is transmitted. A Pakistani doctor in the U.A.E. also said that he was not allowed to talk about the issue, even though he had deported hundreds of Pakistanis in the last five years.

Migrant workers, however, are stepping up to fill in the information void around HIV/AIDS. Nosheen Malik, the principal investigator of the PVDP study, found that workers were interested in volunteering as peer-to-peer educators. Instead of literature, they wanted public health messages through Pashto language music, movies, and stage shows, which they use to relax after tough days at work.

In Pakistan, the New Light AIDS Control Society already relies on peer-to-peer education services to raise awareness among migrant workers in hard to reach rural communities like Jalal Pur Jattan. Their staff have trained members like Tanvir Ahmed and his wife to become advocates for their community. They spread awareness of HIV in their village, bring people to the center for testing, and teach them how to take their medicines. In building an informed community, they hope to reduce transmission rates and prevent an epidemic.