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Pakistan is consist of both federal and provincial administrative areas, and the health care delivery is primarily under the jurisdiction of the provincial government, except for federally-administrated areas (WHO, 2020). Health systems and service provisions are categorized into preventive, promotive, curative, and rehabilitative levels. Secondary and tertiary facilities are primarily responsible for curative and rehabilitative care while preventive and promotive care are rendered by primary health centers through community health personnel and outreach workers. The overall health systems of the country is also a mix of privately-owned and government-led health facilities. A systematic review of databases on the health care systems of Pakistan (Kurji, 2016) revealed that there was little strength in making health policies, participating in Millennium Development Goals (MDGs) program, and improving the efficiency of Basic Health Units (BHU) and Rural Health Centers (RHC). There is also much to do in improving private-public partnerships, human resources, and infrastructures on health. Thus, strong recommendations were made on changing the health systems.
In 2018, there are around 160,000 people living with HIV in Pakistan, and 369% increase in the number of AIDS-related deaths since 2010 (UNAIDS, 2020). In addition, only 14% among PLHIV knew there status while 10% are on ART. This may trigger the continuous increase in the rate of new infections if unaddressed. The extreme conservative culture of the country and the criminalization of same-sex relationship may be considered as contributing factors that prevent key populations from seeking HIV services. A study conducted in Pakistan showed significant increase in discriminatory attitudes towards PLHIV among those with lower level of HIV knowledge (Khan, 2019). In the same study, it was found out that respondents with higher education and in the middle-to-high socioeconomic status showed less discriminatory attitudes toward PLHIV, while men held more tendencies to discriminate. The Human Rights Watch World Report on Pakistan (2019) mentioned 479 attacks against transwomen and intersex people in 2018 alone while a total of 61 killings of transwomen happened between 2015 and 2018. The low level of knowledge, high incidence of human rights violations, and extremist culture-based discrimination against the key populations negatively affect access to HIV care services in this predominantly Islamic country.
The initial discussion with the local CBOs raised some impacts of regressive views toward sex and HIV/STIs which hinders tangible progress on accessibility of sexual health services. Many sexual health-related services are still implemented covertly to not infuriate the general population. Sex among the transgender and MSM community is still considered taboo and sinful to talk about in public platforms. Thus, CBOs approach HIV/STI services through “socially-acceptable” and careful messaging.
As a result, telephone counseling is becoming a more popular part of CBO-based service delivery. Online and website-based services are part of the plans but CBOs in Pakistan are carefully strategizing the implementation.
Despite the passage of Transgender Persons Rights Protection Act 2018, aggressions toward the transgender community continues to exist. The flaws are to be pointed on the implementation, surveillance, and monitoring the effectiveness and efficiency of the policy. As evidenced by the research conducted by the partner CBO in 2019, it was found out that only two in 101 members of the key populations sought legal and law enforcement measures against bullying, harassment, or abuse. As for the killings of the transgender persons, it was mentioned that the Pakistani society campaigned for the forgiveness of the culprits. This is even well-supported by the own families of the transwomen community. This is a pervasive cultural phenomenon faced by transgender persons as they themselves are estranged from their own families. To this date, CBOs in Pakistan try to help the transgender community in however way they can. A paralegal assistance program is currently implemented wherein a transgender person is assigned as an appointed social welfare officer in different police stations so that plaintiffs will feel safe. However, much is still to do with regards to strengthening the Transgender Protection Law in Pakistan.
According to the discussions with CBOs, religion and other “regressive societal norms” are still the most prevailing barriers in successfully curbing the HIV epidemic in Pakistan.
Lessons learned from, and good practices on,
continuity of community-based HIV service delivery
despite the COVID-19 pandemic
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