Baral S, Beyrer C, Muessig K, et al.. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

Johns Hopkins School of Public Health, Baltimore, MD 21205, USA.
The Lancet Infectious Diseases (Impact Factor: 22.43). 03/2012; 12(7):538-49. DOI: 10.1016/S1473-3099(12)70066-X
Source: PubMed


Female sex workers are a population who are at heightened risk of HIV infection secondary to biological, behavioural, and structural risk factors. However, three decades into the HIV pandemic, understanding of the burden of HIV among these women remains limited. We aimed to assess the burden of HIV in this population compared with that of other women of reproductive age.
We searched PubMed, Embase, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine for studies of female sex workers in low-income and middle-income countries published between Jan 1, 2007, and June 25, 2011. Studies of any design that measured the prevalence or incidence of HIV among female sex workers, even if sex workers were not the main focus of the study, were included. Meta-analyses were done with the Mantel-Haenszel method with a random-effects model characterising an odds ratio for the prevalence of HIV among female sex workers compared with that for all women of reproductive age.
Of 434 selected articles and surveillance reports, 102 were included in the analyses, representing 99,878 female sex workers in 50 countries. The overall HIV prevalence was 11·8% (95% CI 11·6-12·0) with a pooled odds ratio for HIV infection of 13·5 (95% CI 10·0-18·1) with wide intraregional ranges in the pooled HIV prevalence and odds ratios for HIV infection. In 26 countries with medium and high background HIV prevalence, 30·7% (95% CI 30·2-31·3; 8627 of 28,075) of sex workers were HIV-positive and the odds ratio for infection was 11·6 (95% CI 9·1-14·8).
Although data characterising HIV risk among female sex workers is scarce, the burden of disease is disproportionately high. These data suggest an urgent need to scale up access to quality HIV prevention programmes. Considerations of the legal and policy environments in which sex workers operate and actions to address the important role of stigma, discrimination, and violence targeting female sex workers is needed.
The World Bank, UN Population Fund.

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    • "These results are in contrast to observed reductions in sexual risk behaviors following HIV diagnosis[43]and initiation of HIV care and treatment among non-FSW populations.444546The null association between behaviors and continuum outcomes in our FSW population may be due to the nature of their work: because their livelihoods depend on high-risk sexual behaviors, FSW may face greater difficulty in reducing transmission risk behaviors following diagnosis and engagement in care than do other populations.[1]The high HIV prevalence identified in our study also highlights the need for HIV prevention among HIV-uninfected FSW. "
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    ABSTRACT: Objective: The HIV care continuum among female sex workers (FSW), a key population, has not been well characterized, especially within the generalized epidemics of sub-Saharan Africa. This was the first study to characterize the HIV care continuum among FSW in Lilongwe, Malawi. Methods: From July through September 2014, we used venue-based sampling to enroll 200 adult FSW in Lilongwe, Malawi into a cross-sectional evaluation assessing HIV care continuum outcomes. Seropositive FSW, identified using HIV rapid testing, received rapid CD4 counts in addition to viral loads using dried blood spots. We calculated proportions of HIV-infected FSW who had history of care, were on ART, and had suppressed viral load and we used Poisson regression to estimate the associations of demographic characteristics and transmission risk behaviors with each outcome. Results: HIV seroprevalence was 69% (n = 138). Among all FSW the median age was 24 years (IQR: 22-28). Among the 20% who were newly diagnosed and reported previously testing negative, the median time since last HIV test was 11 months (interquartile range: 3-17). The majority (69%) of HIV-infected FSW had a history of HIV care, 52% reported current ART use, and 45% were virally suppressed. Of the FSW who reported current ART use, 86% were virally suppressed. Transmission risk behaviors were not associated with continuum outcomes. Conclusions: FSW in Lilongwe were predominately young and have a high HIV prevalence. Only half of HIV-infected FSW reported current ART use, but the majority of those on ART were virally suppressed. To reduce ongoing transmission and improve health outcomes, increased HIV testing, care engagement, and ART coverage is urgently needed among FSW. Universal testing and treatment strategies for all FSW in Malawi must be strongly considered.
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    • "Moreover, only 14.3% of websites explicitly stated that their sex workers are tested for STIs and HIV. This is important as a systematic review and meta-analysis representing approximately 100,000 female sex workers in 50 low-income and middle-income countries found an overall HIV prevalence of 11.8% among female sex workers (Baral et al. 2012). Only one website discussed STI testing of sex tour clients, which was optional for a significant fee. "
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    ABSTRACT: The purpose of this study was to conduct a systematic content analysis of sex tour websites to understand how sex tours are marketed to potential clients. A total of 380 web pages from 21 sex tour websites were reviewed. The sex tour websites sought to promote privacy and hassle-free travel with a local 'escort' and the opportunity for 'hooks-ups' with no strings attached. Three themes emerged around the description of sex workers: (1) enjoyment and complete acceptance, (2) a 'total girlfriend experience' and (3) exoticisation of the 'Third World' woman. The majority of the sex tourism websites used marketplace mythologies concerning racism, sexism and imperialism to appeal to sex tourists' desires for fantasy experiences, power and domination, and a renewed sense of identity. Legal and STI-related information was largely missing from the websites, and when it was included it was aimed at protecting sex tourists, not sex workers. It is of importance for researchers, social workers and others engaging with sex workers and sexscapes to recognise the power of language, cultural myths and framings and their ability to generate real-world social and health implications.
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    • "Transactional sex is a well known risk for, among others things, sexually transmitted infections , post-traumatic stress disorder, depression, substance abuse, physical violence and death (Min et al. 2011, 161–9; Schwitters et al. 2014, 1–9; Vandepitte et al. 2007, 203–8; Zhang et al. 2014, 60–73). As both Shannon et al. (2009, b2939) and Baral et al. (2012, 538–49) illustrate, the nature and severity of these consequences is heavily dependent on social and environmental factors. Sex work often becomes prevalent in areas that are unstable, prone to violence or considered conflict or post-conflict zones (United Nations Populations Fund 2002). "
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