capitals, expanding over time to smaller cities and peripheries. Escalating epidemic - mainly in high risk groups Pakistan faced a low prevalence phase of epidemic from 1987 to 2003. This may have been due to lack of formal surveillance systems, although no study found significant HIV in any group until 2002. In 2003, an outbreak of HIV among injection drug users in one city heralded the onset of HIV epidemic in the country. Since then different studies and the national HIV surveillance (which started in 2004) have confirmed an escalating epidemic among IDUs and more recently among male and transgender sex workers. Currently the national average prevalence of HIV among IDUs is nearly 20%. Several cities also show concentrated epidemic among MSWs/ TSWs as well. However, as mentioned that HIV is taken as stigma in a culture such as that of Pakistan. This along with the absence of routine surveillance and testing for HIV in the health system, ascertaining the actual number will remain a challenge. Other groups that also have HIV among them are truck drivers, expatriated migrant workers and wives of IDUs. However, the incidence rate are not known for the reasons mentioned above. Two studies of men from the general population: Faisel and Cleland and A Study of Bridging Populations (The Population Council/ NACP 2007) show no HIV and few STIs in this group. Similarly a study of women attending labor and delivery clinics in four cities had shown no HIV and rare STIs (NACP 2001). Furthermore, blood donor screening data all over the country are suggesting low HIV infection in the blood donor population, albeit with some increasing trends in selected centers. A number of factors may have contributed to keeping the overall transmission of HIV within the general population. One, Pakistan is a predominantly Muslim country with near universal circumcision. Secondly, taboos on sex may have led to a higher proportion of the need for non-marital sex to be met via sex between men, much from a smaller group of men within each person's acquaintance. Some of this is suggested by the fact that about 45% of all sex acts sold are by either male or transgender sex workers (HIV/AIDS Surveillance Project 2007). These factors may have led to a high rate of HIV transmission among MSM/MSW networks but may (temporarily) slow down the transmission of HIV to the rest of the population. The low