■ Outside the Pir Wadhai bus station, a young man surveys arriving buses for customers. For scores of male sex workers in Pakistan, condom usage remains low. © David Swanson/IRIN

© IRIN/PlusNews, the humanitarian news and analysis service of the UN Office for the Coordination of Humanitarian Affairs.  The opinions expressed do not necessarily reflect those of the United Nations or its Member States.

■ Names of sex workers have been changed to protect their identities.

RAWALPINDI, November 2, 2007 (PlusNews) – Shujaat plies his trade well. As dusk falls on the Pir Wadhai bus station in the Pakistani city of Rawalpindi, the slender 19-year-old gauges disembarking passengers for that ‘look’ – a responsive glance or wink suggesting a desire for more than just a quick bus ride home.

“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, the humanitarian news and analysis service of the UN Office for the Coordination of Humanitarian Affairs.  The opinions expressed do not necessarily reflect those of the United Nations or its Member States.