Bound by 'watta satta', a cultural tradition of exchanged marriage between two families, Nuzhat (not her real name), 22, cannot disclose her HIV status.
"I know well what will happen - I'll be thrown out of my husband's home and my own family will never accept me either. It will also mean my brother's home will be ruined. His wife is my husband's sister and she, too, will be sent packing. In any case, where will I go?" she asked in Karachi, provincial capital of Sindh Province in southeastern Pakistan.
The tradition of watta satta, which literally means 'give and take', or 'throwing a stone and receiving something back', describes the exchange of brides between families, in which a brother and sister from one family are married to a pair from another family, often close relatives.
About a third of all marriages in rural Pakistan take place on a watta satta basis, according to research. In some parts of the country, like Sindh Province, the rate is even higher.
Nuzhat is a classic case of the feminisation of HIV and AIDS that seems to have taken a toll on younger women in the Asia-Pacific region, where the epidemic is being fuelled primarily by the gender inequality that prevails.
Health experts estimate there are 85,000 HIV-positive people in a population of over 160 million in Pakistan - but around 50 percent of them are in Sindh.
According to UNAIDS, almost 40 percent of new HIV cases occur among women, and the Global Coalition on Women and AIDS, a UNAIDS initiative, says women currently represent 30 percent of adults living with the virus in Asia. Accurate figures on the number of infected women in Pakistan are not available.
Entrenched age-old social attitudes, practices and stereotyping, which often lead to violence against women, coupled with unequal access to economic resources, are hampering progress towards dealing with the spread of HIV/AIDS.
Marriage no protection
At the eighth International Congress on AIDS in Asia and the Pacific, held in August 2007 in Sri Lanka, the worrying trend of a rising rate of HIV among young married women was reported.
Dr Naseem Salahuddin, an infectious disease specialist at Karachi's Liaquat National Hospital, notes the increasing transmission of the virus from husbands to their wives: a third of the 200 people living with HIV/AIDS that she has treated since 1998 are women, mostly wives. "It's not just a health issue, and must be looked on as a socio-cultural one," she commented.
Keeping her illness secret out of fear while receiving no treatment is putting unbearable pressure on women like Nuzhat. "I can't keep up a brave face any longer," she lamented.
Dr Saleem Azam has been working with injecting drug users (IDUs) for the last 25 years and has 5,000 IDUs registered with his organisation, the Pakistan Society. In the last few years he has seen a disturbing spread of the virus among IDUs and fears the impact it will have on others, particularly women.
|Open discussion about HIV in Pakistan remains taboo|
Azam convinced Nuzhat's husband to have her tested, but when he first saw her six months ago "she was at a breaking point" and he had to send her for psychiatric counselling. "It's not the stigma she thinks she will face; it's the outright rejection from her family that she knows is there," Azam said.
Nuzhat's husband, Taufiq, a daily wage earner, is not only an injecting drug user - including heroin - but also consumes alcohol and has multiple sexual partners; knowing his HIV-positive status or that he has infected his wife and possibly his daughter has made little difference to his life.
When "there was nothing to eat" at home, Nuzhat decided to get a job. Without proper qualifications she had few options but to work in a local beauty parlour, though she cannot step out without a male escort.
Taufiq maintains his lifestyle on his meagre and sometimes uncertain income because he often beats up Nuzhat and forces to part with her wages, or otherwise he borrows from his mother.
Her health is deteriorating, but her husband takes little notice. "I often get fevers. Boils erupt out of nowhere but I am too scared to seek medical help. I'm always accompanied by some family member. If I go to see a doctor, my mother-in-law will come. What if she suspects something and discloses it?"
Our sole reason for existence seems to be to procreate or provide sexual pleasure for men.
|Our sole reason for existence seems to be to procreate or provide sexual pleasures for men.|
This fear not only stops her from seeking help from one of the centres run by the Sindh AIDS Control Programme (SACP), part of the National AIDS Control Programme, but keeps her from having her two-year-old daughter tested, who is also often sick. "I can't take the risk," she told IRIN/PlusNews.
She felt that women in her family are never given the status of humans: "We are treated like cattle, beaten up regularly on the slightest of pretexts," Nuzhat commented.
"Our sole reason for existence seems to be to procreate or provide sexual pleasures for men. Even my mother thinks that way, as does my mother-in-law. They both live in the city, but it does not mean their mindset has changed. Sometimes I feel ... I'll become like them if I continue living in this suffocating environment."
Discrimination, unequal power relations between men and women, and economic dependence have exacerbated the issue, Dr Azam said. "The unequal power makes women more vulnerable, leading to coercive and violent sex, which often puts them at a disadvantage, with little option to either refuse sex or negotiate for safe and protected sex."