In South Asia, especially in Muslim societies, the issue of men who have sex with men (MSM) has not been adequately discussed, even among those charged with the prevention and control of HIV infection. Pakistan is a Muslim country and issues involving HIV/AIDS have traditionally not been well addressed there. In much of the country, attitudes towards HIV/AIDS range from denial to grudging acceptance to notions of retribution for sinful acts.

Focus-group discussions conducted by the Naz Foundation, an NGO, explored the sociocultural dimensions surrounding sex between men. Participants identified a lack of accessibility to women as the primary reason for this behaviour. The 1200 South Asian men in this study were from India, Pakistan and Bangladesh; they lived either in South Asia or the United Kingdom. The overwhelming majority of these MSM were married. Those aged 14-16 years had an average of 2 sex partners per year, while those aged 17-20 had 5; those aged 21-35 had 42 partners on average, and those aged 36-45 had 35. These extremely high numbers of partners suggest that there is a fertile environment for the spread of STDs including HIV/AIDS. 

Participants explained this male-male sexual behaviour as an alternative to the preferred mode of heterosexual intercourse. In societies that segregate men from women, sex with other men is more convenient and less obvious. Many anecdotal reports describe young men offering to have sex with men or women in exchange for payment. In these cases, economic necessity contributes to having more sexual partners.

Though this type of extensive research has not been conducted in Pakistan, it would not be unrealistic to assume that such behaviour is also prevalent in this country since men there are subject to similar societal values and mores. Indeed, anecdotal reports reveal that the situation may be similar to Bangladesh, another predominantly Muslim South Asian country.

The data on HIV in Pakistan, which come from the National AIDS Programme (NAP), consist largely of cases reported from four province programmes. Only one, the Sind AIDS Control Programme, is active in the field of surveillance, testing and epidemiology. Moreover, the surveillance systems depend on referrals by clinicians; active surveillance is based on convenience sampling with limited samples of risk groups. This situation, together with the sociocultural taboos surrounding sexuality, makes it likely that the total numbers are an underestimate. The cases attributable to MSM and homosexual transmission are also under-represented.

Research on MSM in South Asia currently comes mostly from India and Bangladesh, where dialogue on the issue is more open, in part because the media in those countries discuss sexuality more openly than in Pakistan. Although the cultures of these countries are similar to Pakistan's, expecting the contextual parameters of MSM to be exactly the same in all three would be naive. It is reasonable, however, to assume that an attributable proportion of HIV/AIDS in each country is among MSM and that this population is likely to be lagging in the knowledge and practice of safer sex. It is therefore essential that:

• more formative research be carried out to examine in detail the extent of the MSM population, including qualitative research on knowledge, attitudes and practices regarding safer sex
• confidential HIV testing with associated counselling be initiated
• interventions be developed to increase awareness and education on these issues, based on activities in Bangladesh and India and workshops held in Pakistan.

The last recommendation can be linked with provincial-level training programmes directed towards specific groups such as community and religious leaders, physicians and other professionals. 

Given that it is a matter of time before appropriate research in this area is developed, simultaneous efforts need to be directed towards the policy sector. In Pakistan, efforts in the field of HIV/AIDS have largely been carried out by government agencies, with input from NGOs such as the Pakistan AIDS Prevention Society (PAPS) and the Aga Khan University. PAPs and the Naz Foundation sponsored a consultative meeting of NGO representatives in 1995 focusing on HIV/AIDS issues in Muslim countries (Exchange 1996/2). The meeting discussed the recognition and treatment of HIV/AIDS in Muslim societies as opposed to the current situation in Western societies. Such dialogue is essential in the development of appropriate interventions.

Advocacy for the recognition of specific sub-groups should be started in order to develop an action response. Some conservative social sectors, including persons working in the health field, might have a strong moral apprehension about dealing with same-sex issues. A possible way to side-step the "morality" issue of male-male sex is to address it as a high-risk public health behaviour, given the way it is currently practised. It would then be possible to focus on the potential spread of HIV within this group and the general population.

Working within established institutions may be preferable to adding new initiatives because this would lend sustainability to those programmes with a successful track record in the field. A useful step may be to create a working consortium on HIV/AIDS in the country, with representation from WHO, the NAP, other government agencies and NGOs. The provincial AIDS control programmes, with assistance, could expand their activities and improve their data collection methodologies to encompass MSM. External assistance should be sought from those with experience in developing interventions in this sensitive cultural context, with a conscious effort to establish and sustain research and policy development capacity within the country.