Pakistan’s HIV epidemic is driven by key affected populations. In 1999, Pakistan, in partnership with UNAIDS, determined that it would prevent a generalized epidemicy targeting key vulnerable groups. Subsequent surveillance activities revealed disproportionate HIV risk among injecting drug users and hijra and male sex workers, who exhibit HIV prevalence of 37.8, 7.2 and 3.1 percent, respectively. Targeted HIV prevention interventions among these three groups continue to be the corners tone of Pakistan’s HIV response. Hijra and male sex workers are commonly considered MSM by Pakistani AIDS authorities and so determining whether data correspond to MSM who self-identify as male and are not sex workers is at times difficult.
Sex other than that between husband and wife is strictly forbidden by Islamic law. Consequently, overt expressions of homosexuality carry the risks of social stigmatization, class discrimination, ostracism from family and friends, and extreme physical punishment under current sodomy laws. Yet sex between men appears to exist among segments of society beyond those included in definitions of hijra and male sex workers. More overt examples of male-to-male sexual behavior include the practice of keeping boys for sexual gratification observed among rich elderly men in Khyber Pakhtunkhwa Province.