Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis
Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, Sherman SG, Kerrigan D. Lancet Infect Dis. 2012 Mar 14. [Epub ahead of print]
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. Baral and colleagues aimed to assess the burden of HIV in this population compared with that of other women of reproductive age. They 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 are 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.
Editor’s note: This is the first systematic documentation of the scope and breadth of the disproportionate HIV infection risk that female sex workers bear around the world and the findings are striking. First, only 50 of 145 low- and middle-income countries have published data including measurement of HIV status among female sex workers in the past 5 years. These data gaps are likely due in part to social stigma, criminalisation of sex work, and the USA ‘Prostitution Pledge’ that reduced research interest and funding for studies among sex workers. Without data it is impossible to know whether adequate programming resources are in place and whether they are having the intended impact. Second, sex work, defined here as the exchange of sex for money, carries an occupational risk of HIV infection that is more than 13 times that found in other women of similar age. Sex workers in countries with high HIV prevalence among all women, such as those in sub-Saharan Africa, have lower odds of HIV infection compared to other women than do those in countries with low HIV prevalence, such as India where the risk is 50 times higher. Each country needs to address the structural risk factors that heighten this risk, including legal and regulatory policies and the organisation and power dynamics of sex work. Increasing coverage of HIV prevention programmes, supporting empowerment of sex workers to reduce their risk, and scaling up access for female sex workers living with HIV to antiretroviral treatment for both clinical and prevention benefits are among the urgently needed steps to address the high HIV burden borne by these women.