▁cities ▁and ▁peri ph eries . ▁ ▁Es cal ating ▁ep ide mic ▁- ▁mainly ▁in ▁high ▁risk ▁groups ▁ ▁Pakistan ▁faced ▁a ▁low ▁pre val ence ▁phase ▁of ▁ep ide mic ▁from ▁ 1 9 8 7 ▁to ▁ 2 0 0 3 . ▁This ▁may ▁have ▁been ▁due ▁to ▁lack ▁of ▁formal ▁surve ill ance ▁systems , ▁although ▁no ▁study ▁found ▁significant ▁H IV ▁in ▁any ▁group ▁until ▁ 2 0 0 2 . ▁In ▁ 2 0 0 3 , ▁an ▁out break ▁of ▁H IV ▁among ▁injection ▁drug ▁users ▁in ▁one ▁city ▁her ald ed ▁the ▁on set ▁of ▁H IV ▁ep ide mic ▁in ▁the ▁country . ▁Since ▁then ▁different ▁studies ▁and ▁the ▁national ▁H IV ▁surve ill ance ▁( which ▁started ▁in ▁ 2 0 0 4 ) ▁have ▁confirmed ▁an ▁es cal ating ▁ep ide mic ▁among ▁ID Us ▁and ▁more ▁recently ▁among ▁male ▁and ▁trans gender ▁sex ▁workers . ▁Currently ▁the ▁national ▁average ▁pre val ence ▁of ▁H IV ▁among ▁ID Us ▁is ▁nearly ▁ 2 0 %. ▁Several ▁cities ▁also ▁show ▁concentr ated ▁ep ide mic ▁among ▁MS W s / ▁T SW s ▁as ▁well . ▁However , ▁as ▁mentioned ▁that ▁H IV ▁is ▁taken ▁as ▁st igma ▁in ▁a ▁culture ▁such ▁as ▁that ▁of ▁Pakistan . ▁This ▁along ▁with ▁the ▁absence ▁of ▁routine ▁surve ill ance ▁and ▁testing ▁for ▁H IV ▁in ▁the ▁health ▁system , ▁as certain ing ▁the ▁actual ▁number ▁will ▁remain ▁a ▁challenge . ▁ ▁Other ▁groups ▁that ▁also