Pakistan International Peace & Human Rights Organization
Nindo Shaher District Badin Sindh Pakistan

Pakistan is fertile ground for an AIDS epidemic, due to its low social indicators, economic status, and state of epidemiological transition. (Hyder and Khan 1998) The reported number of HIV-infected cases has been low � up to August 1997 the figure was 1,232. However, the number of total estimated HIV-infected population is as high as 80,000, and the estimated national prevalence figure for HIV is 64 per 100,000. The dominant modes of transmission are heterosexual contact and blood transfusion/blood products. (HIV Working Group 1998)

Only 20 Pakistani children, up to age 19, have been reported HIV-positive. Since children and adolescents are often not even tested out of the mistaken belief that they cannot be sexually active, and most screenings are done of so-called highrisk groups only, we cannot know the real level of infection among them. (Ahmed 1998) As Ahmed explains in her overview of HIV/AIDS and children in South Asia, the disease is a grave issue for children because they are vulnerable themselves to the multiple patterns of transmission and also to the manifold consequences of losing a parent to the disease.

Pakistani children and adolescents are exposed to all of the risks and issues associated with HIV/AIDS highlighted by Ahmed. Mother-to-child transmission may condemn an infected baby to death before age 2, particularly when immunity is low, and death can be caused by diarrhea, measles, tuberculosis, and other respiratory tract infections. Because poverty in developing countries promotes the spread of these illnesses and weakens the immune system, the time from infection to death is shorter for children with AIDS.

Ahmed points out other aspects of the disease pattern which impact children. Male migration, particularly between Pakistan and Gulf countries, has been a source of AIDS transmission and death or social ostracism for wives who become infected. Women and girls are physically more likely to contract HIV from men than the other way around. Women�s lower social status and the high rate of rape in Pakistan further limits their ability to protect themselves from HIV transmission.6 Changing social patterns and urbanization have increased levels of sexual abuse, and child prostitutes and street children are presumably at higher risk of contracting HIV and other sexually transmitted diseases. Finally, young people are also at risk through contaminated blood transmitted through blood transfusions and the increasing use of needles for drug use.

Studies done with high-risk groups in Pakistan do not have age-specific data for adolescents because adults are the focus of the research. However, these studies do mention that men and women can begin their pattern of high-risk behavior while still adolescents. For example, truck drivers have been identified as a potentially important conduit for the spread of HIV/AIDS. Among 35 drivers and truck cleaners, Ahmed et al. (1995) found a high rate of male-to-male sexual contact and contact with female commercial sex workers, as well as a significant rate of drug use. The cleaners were younger than the drivers and included adolescent boys, whose practices were found to be similar. More than half the drivers had been cleaners first, which establishes how they were initiated into this line of work and high-risk behavior. One Indian study of adolescent truck cleaners, quoted in Jejeebhoy (1998), found that 4 percent had a history of sexually transmitted disease, but this figure is likely to be an underestimate.

The commercial sex industry, also a high-risk group, has been the subject of a number of HIV/AIDS prevalence and awareness studies. (Baqi et al. 1998; Khilji n.d.; Manzoor et al. 1995; SOCH n.d.) Baqi et al. (1998) found that the average age of first intercourse for the female commercial sex workers was 14-15 years, and age 11 for male transvestites. Condom use by CSWs was very low. In the Lahore Red Light Area, daughters inherit the profession from their mothers (SOCH n.d.). In one study almost half of CSWs reported they began selling sex at the onset of menstruation. (Manzoor et al. 1995) This is yet another example of how the young are set on the road to high-risk behavior in an environment where knowledge about HIV and others STDs is low and the use of condoms is inadequate.

In a study of 3,392 male prisoners ages 11-81, interviewed in Sindh jails, they reported symptoms of STDs as well as sexual intercourse with multiple partners (male and female). (Khan et al. 1995) They also reported past experiences with commercial sex workers (26 percent) and blood donations (22 percent), and 121 prisoners said that had injected drugs. The study concluded, �prisons in Sindh are potential reservoirs of sexually transmitted diseases� (Khan et al. 1995: 12), and recommended that the Sindh government control the spread of STDs in prisons if it wished to limit the problem among the general population.

There are only 2 juvenile jails in Pakistan. As a result, children find themselves in adult jails, albeit in separate cells, where they experience the same deprivation as older prisoners. According to a survey conducted by the Society for the Protection of Child Rights in 1997, out of a total of 72,714 prisoners in Pakistan, 3,480 were juveniles. Most of them were languishing in jail awaiting trial, while only 282 were convicted. (Fayyazuddin et al. 1998) Juvenile prisoners are therefore likely to be exposed to similar high-risk behavior as their adult, particularly male, counterparts, and therefore at risk of contracting STDs.

Exclusive focus on high-risk groups and behaviors obscures the reality that all citizens of Pakistan, including those who are not sexually active, are at risk of contracting AIDS. For example, everyone is vulnerable to transmission through contaminated blood from hospitals or contaminated needles used in injections, regardless of their age. The risk increases because bad health care practices have resulted in an excessive use of blood transfusions and injections in treating patients. (Khawaja et al. 1997) In Pakistan only 30-40 percent of the blood used for transfusions is being screened for HIV. (UNICEF 1998a)

Some experts argue that the STD epidemic among adolescents is growing globally, probably due to the large proportion of older adolescents who are sexually active either within or outside marriage. (Mensch et al. 1998) Throughout South Asia studies to substantiate or negate this claim are few. However one study from India quoted in Jejeebhoy (1998) reported that the typical patient at STD clinics is a young man barely out of adolescence. In another study quoted by Ahmed (1998) 16 percent of 362 STD cases at a private hospital in Delhi were of children under age 14.

The Karachi Reproductive Health Project undertook a survey to establish a baseline STD prevalence among women in a low-income community in Karachi. (KRHP 1997) Six hundred and one married women between the ages 14-45 were tested for syphilis, gonorrhea, chlamydia, trichomoniasis, and candida in accordance with standards set by WHO and the National AIDS Control Programme. The study found the prevalence of STDs to be extremely low (the highest prevalence was candida at 6 percent) despite that fact that more than half the women complained of vaginal discharge. The researchers recommended modifying the WHO protocol for the management of discharge as it may not be relevant to the population studied. They found that there is confusion surrounding vaginal discharge, and when the WHO protocol is followed to determine the need for testing, it resulted in 500 percent over-treatment. KRHP is currently developing its own protocol to assess vaginal discharge among women and reduce unnecessary testing and treatment.