A SYSTEMATIC REVIEW OF HIV PREVALENCE AMONG FEMALE SEX WORKERS IN LOW AND

MIDDLE INCOME COUNTRIES

STEFAN BARAL, CHRIS BEYRER, KATHRYN MUESSIG, TONIA POTEAT,

ANDREA L WIRTZ, MICHELE R DECKER, SUSAN G SHERMAN, DEANNA KERRIGAN

THE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH

Background

Sex workers are at increased vulnerability to HIV infection through risks mediated by multiple factors

BiologicalUntreated STIs

BehavioralNumbers of sexual partners

StructuralCriminalization and human rights

violations

Primary Aim

We sought to systematically review and meta-analyze the literature on HIV infection among female sex workers from low and middle income countries (LMIC)

Inclusion criteria Any study design measuring HIV incidence or

prevalence among female sex workers in LMIC, including peer-reviewed and publically available reports where sampling, testing and analytical methods documented

Systematic Review Protocol

Search strategy Published January 1, 2007 to June 25, 2011 in English, French, Spanish PubMed, EMBASE, Global Health, SCOPUS, PsycINFO, Sociological

Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine Following search terms

Prostitute [MeSH] or “sex work” or “sex work*” or “female sex worker” or “commercial sex worker” AND HIV [MeSH] or AIDS [MeSH] or “HIV” OR “AIDS”.

Title search Completed by two reviewers with a third acting as tie-breaker Duplicate titles removed and excluding non-scientific journals.

Abstract review Completed by two reviewers with a third acting as tie-breaker

Full text review and data abstraction Completed by two abstractors with a third acting as tie-breaker

Methods

Meta-Analysis Characterize increased odds of living with HIV for

female sex workers compared to other women per country/region Sex worker HIV Prevalence

All estimates from a country were pooled and weighted by sample size to achieve prevalence estimate

Background HIV Prevalence UNAIDS data from Women 15+ living with HIV as numerator in

each country Denominator calculated using US Census Bureau Data for women

15-49

Heterogeneity tests done using DerSimonian-Laird Q statistic

Random effects modeling

Systematic Review Results

Results of HIV Prevalence among FSW

# Of Countries

HIV Positive SW

SW Sample Size

Pooled SW HIV Prevalence

HIV Prevalence Women 15-49

Asia 14 3323 64224 5.2% 0.18%EE/FSU 4 331 3037 10.9% 0.2%

LAC 12 627 10273 6.1% 0.38%

MENA 5 17 959 1.7% 0.43%

SSA 16 7899 21421 36.9% 7.42%

Total 50 12,197 99,878

Total HIV Prevalence among Female Sex

Workers 11.8% (95% CI 11.6-

12.0)

Results in Asia

# Of Countries

HIV Positive SW

SW Sample Size

Pooled SW HIV Prevalence

HIV Prevalence Women 15-49

Asia 14 3323 64224 5.2% 0.18%EE/FSU 4 331 3037 10.9% 0.2%

LAC 12 627 10273 6.1% 0.38%

MENA 5 17 959 1.7% 0.43%

SSA 16 7899 21421 36.9% 7.42%

Total 50 12197 99878Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

HIV Prevalence among Asian FSW

Afgha

nist

an

Bangl

ades

h

Cambo

dia

China

Indi

a

Indo

nesia La

os

Malay

sia

Mongo

lia

Nepal

Paki

stan

Papu

a New

Gui

nea

Thai

land

Vietn

amTo

tal

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

SW Prevalence HIV Prevalence Women 15-49

HIV

Pre

vale

nce

Asia Meta-analysis

Results in Eastern Europe/Former Soviet Union

# Of Countries

HIV Positive SW

SW Sample Size

Pooled SW HIV Prevalence

HIV Prevalence Women 15-49

Asia 14 3323 64224 5.2% 0.18%EE/FSU 4 331 3037 10.9% 0.2%

LAC 12 627 10273 6.1% 0.38%

MENA 5 17 959 1.7% 0.43%

SSA 16 7899 21421 36.9% 7.42%

Total 50 12197 99878Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

HIV Prevalence among EE/FSU FSW

Albania Estonia Georgia Ukraine Total0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

SW Prevalence HIV Prevalence Women 15-49

HIV

Pre

vale

nce

Results in Latin America and the Caribbean

# Of Countries

HIV Positive SW

SW Sample Size

Pooled SW HIV Prevalence

HIV Prevalence Women 15-49

Asia 14 3323 64224 5.2% 0.18%EE/FSU 4 331 3037 10.9% 0.2%

LAC 12 627 10273 6.1% 0.38%

MENA 5 17 959 1.97% 0.43%

SSA 16 7899 21421 36.9% 7.42%

Total 50 12197 99878Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

HIV Prevalence among LAC FSW

Argen

tina

Brazil

Chile

Guate

mal

a

El S

alva

dor

Guyan

a

Hondu

ras

Jam

aica

Mexico

Nicara

gua

Para

guay

Tota

l0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

SW Prevalence HIV Prevalence Women 15-49

HIV

Pre

vale

nce

HIV Prevalence among LAC FSW

Results in Middle East/North Africa

# Of Countries

HIV Positive SW

SW Sample Size

Pooled SW HIV Prevalence

HIV Prevalence Women 15-49

Asia 14 3323 64224 5.2% 0.18%EE/FSU 4 331 3037 10.9% 0.2%

LAC 12 627 10273 6.1% 0.38%

MENA 5 17 959 1.7% 0.43%

SSA 16 7899 21421 36.9% 7.42%

Total 50 12197 99878Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

MENA HIV Prevalence among FSW

Egypt Somalia Sudan Tunisia Total0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

SW Prevalence HIV Prevalence Women 15-49

# Of Countries

HIV Positive SW

SW Sample Size

Pooled SW HIV Prevalence

HIV Prevalence Women 15-49

Asia 14 3323 64224 5.2% 0.18%EE/FSU 4 331 3037 10.9% 0.2%

LAC 12 627 10273 6.1% 0.38%

MENA 5 17 959 1.7% 0.43%

SSA 16 7899 21421 36.9% 7.42%

Total 50 12197 99878Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

Results in Sub-Saharan Africa

HIV Prevalence among SSA FSW

Benin

Guine

a

Sene

gal

Camer

oon

Togo

Niger

ia

DR Con

go

Ugand

a

Kenya

Malaw

i

Rwanda

Sout

h Afri

ca

Zimba

bwe

Maurit

ius

Comor

os

Madag

asca

r

Tota

l0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

SW Prevalence HIV Prevalence Women 15-49

HIV

Pre

vale

nce

SSA FSW Meta-analysis

Map of HIV prevalence among female sex workers in low-income and middle-income countries, 2007-2011

Pooled OR for HIV infection among female sex workers compared to other women of reproductive age (15-49) 13.49 (95% CI 10.04-18.12)

Limitations

Data available for 50/145 LMIC meeting inclusion criteria 2/3 of LMIC do not have HIV prevalence data on sex workers

available in public domain indicating need for systematic data Significant heterogeneity of study results

Some heterogeneity addressed by sub-level analyses by region

However, pooling even at regional level masks wide geographic variations within a country or region such as within India

Background rates among women may include HIV infections among female sex workers Sensitivity analyses completed removing infections

attributable to FSW from background

Conclusions

Three decades into the HIV pandemic, epidemiological data characterizing risk status and needs of sex workers remains limited Global policy environment limits comprehensive assessments of HIV

prevention and service delivery needs of sex workers across settings

In all epidemic types and contexts, the burden of HIV is much greater among female sex workers as compared to the general population Particularly, in the generalized epidemics of Sub Saharan Africa, female

sex workers represent an underserved and higher risk population group

These data represent a call for action to invest in and address the needs of sex workers to prevent HIV, including evidence-based comprehensive HIV prevention strategies which protect and promote their human rights

Acknowledgements

JHSPH Data Review Madeleine Schlefer

World Bank Robert Oelrichs Iris Semini Ndella Njie

UNFPA Jenny Butler

NSWP Ruth Morgan Thomas

Funded by the World Bank and UNFPA