A Surprise in Pakistan

Two years ago, if someone had asked me if there were significant numbers of people practicing high-risk behaviors for HIV transmission in small towns in Pakistan, I would have said, "Not very likely." These are, after all, very conservative communities. Extended family networks and social taboos would restrict sex work and injecting drug use to very small groups operating in difficult-to-find locations. But in town after town (we surveyed 12 across Pakistan), we identified large and very active communities of sex workers and injecting drug users. These social mapping studies (conducted in collaboration with the London School of Hygiene and Tropical Medicine) have helped estimate the number and location of persons at high risk of HIV infection in smaller towns in Pakistan. In Haripur, a town of 56,000 people in the North-West Frontier Province, for example, we estimated there are at least 390 sex workers and almost 100 transgendered sex workers. We are helping the government better target HIV prevention programs, including smaller towns and not just urban centers.

The challenging work was not without its lighter moments. Late one night, following a long day of field interviews, I shared a taxi back to Islamabad with four of our field workers. While waiting in our taxi at a traffic light, I saw a policeman stare in disbelief at the motley crew in the little hatchback. Two of our field workers were female sex workers, one a male sex worker, and the last, a transgendered sex worker who stood out in her colorful dress and mannerisms. I turned to the back of the taxi to see what all the giggling was about, and saw her cheerfully teasing the policeman, who was obviously not amused.

Only a green light saved me from a substantial bribe and a very difficult explanation.