BackgroundThe Hijra is a distinct type of gender role in South Asia where men act like women. This group of people is socially excluded by the general community, in terms of attainment of an opportunity for a socially productive life. Often this sort of deprivation forces these individuals towards professions like sex trade, in pursuit of sustenance, which as a consequence places them as a key block in the puzzle of an impending generalized HIV epidemic in Pakistan.MethodsThis study is a qualitative study, which involved 8 in-depth interviews and four focus group discussions, conducted in Rawalpindi and Islamabad (Pakistan) from February to April 2012. The data was audio taped and transcribed. Key themes were identified and built upon. The respondents were contacted through a gate keeper Hijra who was a member of the hijra community. Multiple interview sessions were conducted with each respondent.ResultsTwo key categories of the Hijras were identified as Khusrapan and Zananapan, during the in-depth interview sessions. This initial information paved way for the four focus group discussions. The data was presented using key themes which were identified. The study participants explained their life histories to us which made it obvious that they had been socially excluded at many stages of their lives from performing normal social functions. This lack of occupational and educational opportunities pushed them towards entering the risky business of selling sex.ConclusionThe transgender community is socially excluded by the Pakistani society which is leading them to indulge in commercial sex and putting their lives at risk. Prudent measures are needed to form community based organizations managed and led by hijra community and addressing their social exclusion and risky behaviors.

BackgroundStreet children are a global phenomenon, with an estimated population of around 150 million across the world. These children include those who work on the streets but retain their family contacts, and also those who practically live on the streets and have no or limited family contacts. In Pakistan, many children are forced to work on the streets due to health-related events occurring at home which require children to play a financially productive role from an early stage. An explanatory framework adapted from the poverty-disease cycle has been used to elaborate these findings.MethodsThis study is a qualitative study, and involved 19 in-depth interviews and two key informant interviews, conducted in Rawalpindi, Pakistan, from February to May 2013. The data was audio taped and transcribed. Key themes were identified and built upon. The respondents were contacted through a gatekeeper ex-street child who was a member of the street children community.ResultsWe asked the children to describe their life stories. These stories led us to the finding that street children are always forced to attain altered social roles because health-related problems, poverty, and large family sizes leave them no choice but to enter the workforce and earn their way. We also gathered information regarding high-risk practices and increased risks of sexual and substance abuse, based on the street children’s increased exposure. These children face the issue of social exclusion because diseases and poverty push them into a life full of risks and hazards; a life which also confines their social role in the future.ConclusionThe street child community in Pakistan is on the rise. These children are excluded from mainstream society, and the absence of access to education and vocational skills reduces their future opportunities. Keeping in mind the implications of health-related events on these children, robust inter-sectoral interventions are required.

Ebola virus disease (EVD) has mostly affected economically deprived countries as limited resources adversely affect a country’s infrastructure and administration. Probing into the factors that led to the widespread outbreak, setting forth plans to counter EVD cases in developing countries, and devising definitive measures to limit the spread of the disease are essential steps that must be immediately taken. In this review we summarize the pathogenesis of EVD and the factors that led to its spread. We also highlight interventions employed by certain countries that have successfully limited the epidemic, and add a few preventive measures after studying the current data. According to the available data, barriers to prevent and control the disease in affected countries include irresolute and disorganized health systems, substandard sanitary conditions, poor personal hygiene practices, and false beliefs and stigma related to EVD. The public health sector along with the respective chief authorities in developing countries must devise strategies, keeping the available resources in mind, to deal with the outbreak before it occurs. As a first step, communities should be educated on EVD’s symptoms, history, mode of transmission, and methods of protection, including the importance of personal hygiene practices, via seminars, newspapers, and other social media. A popular opinion leader (POL) giving this information would further help to remove the misconception about the nature of the disease and indirectly improve the quality of life of affected patients and their families.Electronic supplementary materialThe online version of this article (doi:10.1186/s40249-015-0048-y) contains supplementary material, which is available to authorized users.

Background Pakistan’s National AIDS Control Program has registered 44,000 HIV/AIDS patients to date, but the actual number of cases have been estimated to be as high as 150,000–170,000. The health care system has a very important role to play in this equation and must be reformed to improve the health care services in Pakistan, with regards to HIV/AIDS. Methods It was a qualitative research employing a phenomenological approach. The principal researcher visited nine public and private health care facilities and conducted 19 key informant interviews with people working for providing preventive and curative services, in addition to the observations made on the site. Results Pakistan’s health system has a limited capacity to address the HIV spread in the country, with its current resources. There is an obvious scarcity of resources at the preventive, diagnostic and curative level. However, menace can be curtailed through measures taken at the service delivery level by checking the unsafe needles practices, unclean surgical procedures and an unregulated and untrained private health workforce which are dangerous potentials routes of transmission of the virus to the general population. Healthcare establishments carry the chances of nosocomial infections including HIV/AIDS. Poverty, illiteracy and stigma associated with the disease is compounding the overall situation. Conclusion Improved accessibility to service delivery with a greater focus on prevention would be imperative to address the threat of HIV/AIDS in Pakistan. A health systems approach would help in identifying gaps at both strategic and operational levels, and concurrently find and implement solutions.

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Pakistan has moved from a ‘low prevalence–high risk’ to a ‘concentrated epidemic’ state, yet the forcefulness required for managing this silent escalation of HIV infected numbers is not being highlighted, as it should be. A more comprehensive review of the national strategy for HIV/AIDS would necessitate a system's thinking. For this purpose, the WHO's Health Systems Building Blocks have been discussed to analyse whether this framework can be employed to take some corrective measures. An extensive literature review in this regard helps to understand that the service delivery has to be responsive, but skilled human resources, a robust information system, an uninterrupted supplies and use of latest technology, adequate financing, and above all good governance at operational level are essential ingredients, which call for re-orienting the national programme today. Lack of coordination, capacity, and interventions with questionable sustainability pave a perilous path. Hitherto, the issue can be addressed by involving stakeholders from all levels of the society and managing the void between policy and implementation. Furthermore, interventions that focus on the long-term future are imperative to combat the menace threatening human lives.

Structural violence was first defined by Johan Galtung as “A form of violence wherein some social structure or social institution may harm people by preventing them from meeting their basic needs”1 The concept has been studied extensively over the years and is considered as a major reason for strangled development in various resource limited settings around the world. The idea of structural violence implies that people in power fail to provide essential services for the people they are responsible for; this failure can be intentional or unintentional, nevertheless long-term effects influence the marginalized population adversely.2

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