Well, they have been transformed, and they haven’t been transformed. Take female sex workers, for example, the focus group for targeted interventions. Over successive biobehavioral rounds that we have been doing from 2005-2006, very elaborate surveys, the results show that the prevalence of the epidemic is increasing among drug users, but there isn’t much in female sex workers. They in fact have the lowest prevalence among the different risk groups and it is not increasing; female sex workers are thus not as much at risk of contracting HIV as male sex workers, hijras, transgender, or injecting drug users. But then, the question then is, why do they continue to be on the priority list, if there is no evidence to support that they are at risk because you do not find HIV among them? There are other kinds of structural risks – of violence, vulnerability, everything – but the evidence suggests they are not at HIV risk, because there is hardly any prevalence. So why don’t you divert those resources to the target groups where prevalence is increasing – like injecting drug users, where the prevalence has reached 50% in some of the cities? But then, female sex workers continue to be on top of the agenda because this is the category that comes with funding, this is one of the original categories that continues to persist despite the lack of evidence on the ground.
Maybe there are some shifts happening now that are driven from below. A lot of data shows that the women coming to treatment centers are not female sex workers, but housewives – of migrants, of injecting drug users – and female injecting drug users. Now interventions are trying to strategically shift the focus to these vulnerable groups.
Additionally, male sex workers constitute a category that, as in other places, has been broken down into male sex workers and men who have sex with men because experience suggests they might experience different types of vulnerability. Then within these categories, there is debate about whether there need to be different kinds of tailored interventions to address different sets of vulnerabilities and power relations.
So in this sense, the categories have been tweaked and people have attempted to refine them, but there hasn’t been much success in shifting the interventions because donors tend to work at the level of categories that have worked in other places as well.
So it seems that funding streams seem to shape the virus’ travels and the corresponding epidemic of significations. How much of this response is donor-driven?
In Pakistan, it is very much donor driven. In a nutshell, the HIV/AIDS response was set up by the WHO in the late 1980s, supported by the World Bank and bilateral agencies, and then scaled up massively by the World Bank in the early 2000s. There has been some resistance by bureaucrats and health experts against giving too much leverage to donors to decide where we should invest. Bureaucrats and health experts have been particularly concerned that the aid conditionalities accompany donor funds, in the light of structural adjustment policies, would result in increased privatization and reduce the role of the government.
How have these dynamics and the ensuing interventions changed notions and categories of sexuality?
The World Bank got involved because of the threat HIV/AIDS posed to the economy. So donors have not been necessarily concerned with health of people on its own, but in tandem with the economy as a problem of development. Interestingly, as HIV/AIDS interventions scaled up through the involvement of these donor agencies, there was the concomitant rise of the participatory approach to development.
Now, the participatory approach to development that was popularized over the 1990s emphasized the involvement of all stakeholders – the government, the donors, and significantly, the target populations. As a result, meetings started to include not only bureaucrats and donor representatives, but also people from civil society, NGOs, private sector, academia, and perhaps most profoundly, people who are at risk of HIV – which meant injecting drug users, female sex workers, hijra communities, and male sex workers.
Imagine now how the meetings were completely transformed by this scale-up. Before that, you had government bureaucrats working with donors. Now, you have all these different people. So in the meeting you now have a transgender sitting as an equal partner, a stakeholder, who would not be there were it not for the participatory approach. So in that sense this foreign funding provided occasion to people who were hiding their status to come out and be a voice of different marginalized groups, including those who are at the margins because of their sexuality and gender.
These people then become examples for others to follow, For example, if an HIV positive person is part of a meeting where he is sitting face-to-face with the health secretary or a World Bank representative and then he can go back and tell his community about the experience, others can then begin to envision themselves in a similar position. Why is he in that position? Because he is putting his HIV+ status to use. You can take that and apply it to other categories as well, of marginal sexualities and genders.
The story that you’re telling is celebratory; it suggests that people have put their HIV status ‘to use’ through targeted interventions. But is there a flip side?
Actually, government bureaucrats and officials have also learned how to capitalize on this participatory approach – in ways that I do not think have always been beneficial.
I was in a discussion, for example, where policymakers and stakeholders were deliberating on the next funding proposal, and this lady who was convening the meeting said at one point, “Oh let’s put that word in the proposal… that word that I’m forgetting now… Oh yes… ‘sexual minorities!’ Yes, let’s put that word in the proposal. These are the kinds of words that will get us funding from international donors.”
So bureaucrats like her have now learned this language of participation and this language which describes marginality and they are making use of that language to get more funding. What most bureaucrats didn’t do, very sadly, is learn from the actual lives of people identified as “targets.” Certain colleagues would even ridicule the activists who would try to claim equal partnership behind their backs.
We’ve talked about north-south flows of the virus, its significations, and funding, but how do south-south geopolitical dynamics shape HIV/AIDS in Pakistan?
One of the most obvious south-south connections requiring attention is that between Pakistan and the Gulf Region. Migration to the Gulf Region is part of the problem and there is hardly any cooperation to address the problem.
It is part of the problem because Gulf countries do not allow these labor migrants to bring their families to live with them, so they live in bachelor hostels and work sites and – I am not blaming migrants here – but because of the circumstances in which they are kept in these countries, they are more likely to engage in unsafe sex. Then, if they are found to be HIV positive, they are deported back to Pakistan. In many cases, they are deported without the knowledge that they are HIV positive. So they end up here without knowing what is wrong with them, and here they might get into drugs or multiple partners, or they have their wives, and HIV consequently spreads.
At the same time, there is no advancement improving cooperation and information exchange around HIV/AIDS between countries because Gulf countries do not want to be associated with HIV. They do not want to tell the WHO and the world that X number of people were infected while working in our country. Pakistan doesn’t press the matter because if we press the matter, the Gulf countries would say, okay, well we are not going to take any more migrants from your country, we’ll just take more migrants from elsewhere. So on Pakistan’s side, this is migration diplomacy. The south-south cooperation that is needed is not there, and nobody talks about it because of the concern for maintaining markets for labor.