Four women in a support group of more than 20 people living with HIV in the eastern Pakistani town of Lahore have been infected with the virus by their husbands, who contracted it while they were working in Dubai.

"Two knew that their husbands were HIV-positive, but didn't know how to protect themselves from getting it,"says Nazir Masih, leader of the New Light AIDS Awareness Group that has been working in a working class neighbourhood of Lahore for the last few years.

Nazir is the first person in Pakistan to have gone public with his HIV status, which continues to be seen as the result of infidelity — an act that is seen as both un-Islamic and immoral and carries the death penalty under Islamic laws.

The attached social stigma and the myths about HIV/AIDS have forced those infected to keep silent. "It is this fear of backlash from one's family or community that stops so many people from even seeking treatment. One can well judge the situation of women who contract HIV, even if (it is) from their husbands," Nazir says.

For his outspokenness, Nazir has paid a personal price. A government-run testing laboratory in Lahore that he had publicly targeted for its insensitive handling of infected people declared that his 17-year-old daughter was HIV-positive.

Although her health status was cleared by several other laboratories, the first report was hard to live down for Nazir because it imputed that either he had had sex with his daughter or the teenager was not a virgin. "They only did it to humiliate me because I had contested their test results that declared all the members of our group were HIV-negative," he says.

Dithering over decisions

According to the United Nations Joint Programme on HIV/AIDS (UNAIDS), the stigma and misconceptions about HIV/AIDS that are prevalent in Pakistani society are also reflected in government decision-making.

"Unfortunately, this translates into political indecisiveness, development of ineffective policies and programmes, and inadequate budget appropriations," said UNAIDS in a recent report on the situation and response to AIDS in Pakistan.

UNAIDS has also questioned the reliability of official data on the magnitude of the disease. The government puts the figure of the HIV-infected at 1,900 at the end of 2001, which is a prevalence rate of 0.1 percent.

"The number of cases is much higher than what is officially reported. The reliability of the available data is limited," states UNAIDS in a statement. Unofficial figures peg the figure at more than 90,000.

While the presence of four HIV-positive women in Nazir's group suggests a high infection rate among Pakistani women, the government says the incidence is relatively low — 13 percent of the total reported cases up to the end of last year. However, it acknowledges women's high vulnerability to HIV and other sexually transmitted diseases.

Lack of understanding

But this acknowledgement is not reflected in its actions, particularly its awareness raising efforts in the media, which, according to public health experts, have done little to change people's understanding about the reasons for the spread of HIV among women.

Bashrian Bibi, a domestic helper in the Pakistani capital city Islamabad, has watched the spots on television but cannot say what HIV/AIDS is and whether she can be infected.

"Why would I get it when I am married?" she asks, echoing the views of a majority of married women who think it can be contracted only from sex outside marriage.

"To stay subtle in its awareness campaign, it (government) has generalised the spread of infection to an extent that most people think they cannot get it," says a public health expert who asserts that such messages do more harm than good.

" 'Everybody is at risk of being infected by the AIDS virus' should be the crux of any awareness campaign," says Mohammad Azhar, a pharmacist who works with a public health group.

In fact, the government's own data, prepared by its National AIDS Control Programme (NACP), suggests that heterosexual transmission currently accounts for the majority or 37 percent of reported HIV cases.

This is followed by contaminated blood or blood products (18 percent), injecting drug use (4 percent), homosexuality (2 percent), bisexuality (1.5 percent) and mother-to-child transmission (1.3 percent).

The transmission modes for 36 percent of the reported HIV cases are unknown, though it is assumed that most of these cases are associated with sexual behaviour, says Dr Birjees Tahir, who heads the NACP.

Avoiding infection

The NACP notes that most HIV-positive women have contracted the infection from their husbands, but would not give the exact number of such cases.

"It might be a good idea if women know this fact and be empowered to avoid infection in perfectly legitimate sexual relationships. This itself is a proof that sexual adventurism is not just the only cause, as is being perceived and propagated," says Shahina Maqbool, who writes on health issues.

She says the government's anti-HIV/AIDS campaigns should at least reflect the NACP data and target the vulnerable groups accordingly.

"There needs to be clear-cut messages about the ways one can contract the infection, especially its heterosexual transmission. This should be addressed to women in particular as most are illiterate and at the same time have no control over choosing the safest contraceptive," she adds.

Gender focus

The National Plan of Action prepared by the Pakistan government as a follow-up to the 1995 Beijing women's conference recognises the fact and calls for a special gender focus for the government-run NACP.

Similarly, UNAIDS and the World Bank have pointed out in separate reports that it is not only sex workers and migrant workers whose behaviour makes them vulnerable to the pandemic.

Pakistani women of all social and economic classes face varying degrees of discriminatory and repressive behaviour that not only reduce their life chances, but make them vulnerable to the virus.

While the fear of backlash inhibits the care-seeking behaviour of infected women more than men, its high cost is also a major impediment.

"My husband died six years ago in five months after his infection turned into full-blown AIDS. We just couldn't afford to pay for the high cost of medicines and food," says Parveen Hashim, who lives in Lahore. — IPS