"Here you can find all sorts; mostly truckers, soldiers, day labourers, and of
course married men," he said, leaning against the wall.
"I always find someone," the now veteran male sex worker (MSW) boasted.
After three years on the streets, Shujaat's confidence is dwarfed only by his
ambivalence towards contracting HIV - a virus that he and other men who have
sex with men (MSM) are increasingly at risk of.
"I'm careful and I'm clean, so what's the problem," he asked?
But for medical experts in Pakistan, a nation which until recently enjoyed a
low prevalence for the virus, this line of thinking is worrying.
The South Asian nation of more than 160 million inhabitants now faces a
concentrated epidemic among certain high risk groups - particularly intravenous
drug users (IDUs), estimated at close to 200,000.
In the country's commercial capital of Karachi alone, a reported 30 percent of
IDUs are infected with HIV
Pakistan's National AIDS Control Programme (NACP) officially confirms just over
3,000 HIV/AIDS cases across the country, while health experts assess the real
numbers to be much higher.
According to UNAIDS, about 85,000 people are living with HIV in Pakistan today.
And while the issue of IDUs is often discussed in the media, the issue of MSM
is usually ignored; a troubling reality in conservative Pakistan, where
homosexuality is not only not discussed - it is often denied.
The male sex worker - a taboo subject
"It is very difficult to talk about sex and sexuality in Pakistan and more
difficult to talk about homosexuality," said Dr Naeem-ud-Din Mian, chief
executive officer for Contech International Health Consultants, a local NGO
recently assigned a five-year project for the delivery of preventive services
for MSM in the city of Faisalabad by the Punjab AIDS Control Programme and the
World Bank.
Echoing that, Brian Miller, field coordinator for the Organisation for Social
Development, a local NGO running an outreach programme near Pir Wadhai
remarked: "People know about it, but it's a taboo subject as it's not in
keeping with Pakistan's Islamic social setting."
As a result, open discussion about MSWs is all but impossible, despite the fact
that most health experts in the country now view MSM, many of whom are married,
as the singular most at-risk group after IDUs - and an important bridging
population into mainstream heterosexual Pakistani society.
Government health figures reveal prevalence rates among IDUs of up to 27
percent, with around seven percent among MSM.
According to the Infection Control Society of Pakistan (ICSP), another NGO
targeting the prevention of HIV/AIDS among MSWs in Karachi, around half of the
MSWs in the city are married, while more than half of the unmarried MSWs buy
sex from female sex workers - underscoring the group's capacity to act as a
conduit to the virus's spread.
"They're the next risk group," Naseer Muhammad Nizamani, country director for
Family Health International (FHI) in Islamabad - which is actively engaged in
promoting safer sex practices among MSM and MSWs in the country - said about
MSWs.
The US-based NGO estimates that there are some 50,000 MSWs in Pakistan, while
others estimate their numbers are much higher.
ICSP says that in Karachi alone, there are between 40,000 and 50,000 male sex
workers, depending on the criteria used.
The impact of poverty
Although many MSWs are gay, poverty, lack of job opportunities and broken homes
appear to be the driving force behind this activity.
The majority of MSWs are below the age of 24 and began work at the age of 16,
with many starting out under the guise of providing massage to men.
Today 'Malishias' - as they are commonly known - have become a common euphemism
for sex in Pakistan, attracting their clients by massaging their private parts
and masturbating.
"Massage boys are a traditional way of this happening. It's a big business in
Pakistan," Nizamani said.
The average charge per sex act averages between just US$1 and $3. Pricing in
turn largely dictates the number of clients a boy may be prepared to service on
a given day.
According to an NACP survey carried out in eight separate cities, most MSWs
average 2.3 customers a day or more than 31 a month. This is even higher among
members of the 'Hijra' (transgender) community.
One Hijra, who had no other source of income, said she could easily service up
to 20 men in a single day.
"There is no limit to the number of customers and no limit to the service," she
told IRIN/PlusNews openly.
Insufficient services and low condom use
Despite such candour, however, there are limits to levels of awareness among
MSWs, most of whom have no real understanding as to how the virus is contracted
or simply fail to use condoms to protect themselves.
"People have heard of AIDS. But when you go deeper into what proportion
actually know how the disease is contracted, that's something else," FHI's
Nizamani said.
Although the NACP survey revealed that 70 percent of MSWs knew something about
HIV and that a large majority of those who had heard about HIV also knew that
it could be transmitted through sexual intercourse, less than half knew that
injections could transmit HIV.
In Karachi, ICSP found that just 18 percent of MSWs in that city knew about
HIV, its preventions and modes of transmission, while the NACP survey found
that only about 60 percent reported condom use as an HIV prevention method - a
fact largely dictated by money.
"I don't use a condom," 25-year-old Javed, who works in Rawalpindi, told
IRIN/PlusNews. "They [the customers] complain that they don't feel the same
amount of pleasure."
"If the customer wants to have sex without a condom and is willing to pay for
it, how can I refuse," another MSW, who declined to give his name, asked?
Less than 25 percent of MSWs reportedly used a condom for anal sex with their
last client, and even fewer used any form of lubrication aside from saliva.
According to Dr Kartar Lal of ICSP, 74 percent of MSM use saliva and oil in
place of water-based lubricants, which facilitates the virus's spread.
"In-depth interviews of target groups revealed a significant proportion of
these individuals are aware of the risks associated with unprotected sex, but
are unable to negotiate safe sex practices with their partners," said Dr Rafiq
Khanani, ICSP's president.
Male sex workers cite reasons of low self esteem, lack of empowerment and a
genuine fear of losing the client to other sex workers willing to provide the
service without a condom.
"It's very hard to speak openly about condom usage," Miller reiterated. "It's
simply not done in a country like Pakistan."
He said the government had done little to publicly support the use of condoms
or their distribution, given the strong religious opposition in the country.
According to UNAIDS, less than 10 percent of people most at risk of contracting
HIV, such as MSM and drug users, receive preventative services.
IRIN/PlusNews
