The key factors that have been found to be associated with HIV positivity among HSWs in Larkana include younger age, being unmarried, sex work as the only mode of income and longer duration in sex work (5–10 years). Moreover, most of the HSWs in Larkana entertained multiple partners in previous months compared to HSWs from other cities (Table ). HSWs of Larkana were more likely to lack knowledge regarding preventive measures for HIV. A sizeable proportion of HSWs in our study reported indulging in unprotected anal sex with multiple male partners, both casual and commercial, in the previous month.
Recent studies have shown that high partner turnover along with the lack of knowledge regarding preventive measures has led to a rapid rise in HIV prevalence among sex workers in several Asian cities including Bangkok, China, Indonesia, Nepal and Pakistan [9
]. Pakistan progressed to concentrated level of the epidemic in 2005. During that time four per cent of surveyed male sex workers in Karachi were found to be infected and within two years, that figure had nearly doubled. The results of Round III of surveillance indicated an overall 6.4% HIV among HSWs in the country. The 2008 IBBS data and the analyses undertaken in the present study suggest that HSWs in the country and more so HSWs from Larkana are at increased risk of acquiring HIV infection.
This high prevalence of HIV was alarming. Regional data also indicate that HSWs are at elevated risk for HIV infection in many low and middle income countries of the region like Indonesia, Nepal, Vietnam, China and India [11
The health and social services in Larkana are already fragmented compared to other sites. For example the infant mortality rate of Larkana is 84/1000 live births whereas IMR of Karachi is 40 and Lahore is 50 [18
]. More so HSWs are intimidated to seek health services because of the attitude of health care providers.
HSWs in Larkana get engaged in sex work at a relatively early age that increases their vulnerability to HIV. Most probable reason for HSWs to engage in commercial sex in Larkana at an early age is client competition related to the unique feature of the city with a functioning brothel (FSWs) and mini brothels “musafirkhanas” where clients can seek services of young boys as well.
They come in commercial sex without prior knowledge of safe behaviors and get infected with HIV compared to HSWs from other parts of the country. Several other measures of sexual risk behavior were also reported more frequently by Larkana HSWs than others.
Even though HSWs in Larkana knew that HIV can spread through blood transfusion but many of them also thought that HIV can also spread through kissing and hugging. They also had quite inadequate knowledge regarding modes of prevention of HIV as in response to the question regarding knowledge of prevention of HIV majority of HSWs in Larkana replied “no” when asked if prevention is possible by refraining from sex (OR: 6.1313, CI: 3.9–9–58). HSWs in Larkana did not know where people could go, if they want to get an HIV/AIDS test (OR: 1.91, CI: 1.31–2.79). It actually indicates lack of access and social barriers to seek help if needed. This is discovered in other global surveys as well that sex workers have inadequate access to HIV prevention services, and even more limited access for appropriate treatment, care and support [11
]. The epidemiological data on HIV infection rates among sex workers and their clients reflects the failure to adequately respond to their human rights and public health needs. It may also be due to stigma of or being identified as a person at high risk for HIV. While the global response to the pandemic has progressed over the decades both in scale and in efforts to reach diverse and vulnerable groups, stigma and discrimination still follow affected individuals in many settings [17
Findings from multivariate analysis showed that the HSWs from Larkana were more prone to use of alcohol during anal intercourse. This is a significant finding but not surprising because drunken HSWs are more likely to ignore safe sex. Literature also points to the use of alcohol and other psycho stimulants as a risk factor for HIV infection among HSWs [22
]. Substance abuse is also known to be associated with prolonged and rough anal sex, which when combined with reduced condom use, would appear to be a fairly dangerous combination. Increasing consistent condom use is of utmost importance for HIV prevention.
Study findings reinforce the need to develop and implement effective behavioral interventions for HSWs in general and Larkana HSWs in particular in order to reduce transmission risk. Most interventions that target MSM have been developed for “gay” self-identified MSM as well whose sex partners are predominantly other men. However, male clients of these HSWs who have both male and female partners, may not be reached by or respond to such interventions. In Pakistan, locations where “Hijra sex workers” work are fairly well established, and it may be feasible to use different strategies and messages. In these settings, it is possible to target sex workers with a full range of risk reduction messages that address both vaginal and anal sex. Moreover evidence based strategies to address the social and financial support needs of sex workers constitute integral component of effective and comprehensive response to HIV. UNAIDS has given a framework based on three pillars to address HIV and sex work i.e.
Pillar 1: Assure universal access to comprehensive HIV prevention, treatment, care and support.
Pillar 2: Build supportive environments, strengthen partnerships and expand choices.
Reduce vulnerability and address structural issues [26
Working in partnership with sex workers to identify their needs and to advocate for policies and programs that improve their health, safety and engagement in the AIDS response is a proven strategy and an essential feature of UNAIDS approach. Partnerships at national, local and community levels should be strengthened to remove the barriers that sex workers face to service access and their human rights. In addition drivers of the epidemic like social exclusion, stigma and discrimination of HSWs should be addressed. One of the strategies to address could be development and empowerment of transgender community based organizations which exist in negligible number in Pakistan and none in Larkana.