1. 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

2. Background  Sex workers are at increased vulnerability to HIV infection through risks mediated by multiple factors Biological Untreated STIs Behavioral Numbers of sexual partners Structural Criminalization and human rights violations

3. 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

4. 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

5. 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

6. Systematic Review Results

7. 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 3323642245.2%0.18% EE/FSU 4 331303710.9%0.2% LAC 12 627102736.1%0.38% MENA 5 179591.7%0.43% SSA 16 78992142136.9%7.42% Total5012,19799,878 Total HIV Prevalence among Female Sex Workers 11.8% (95% CI 11.6-12.0)

8. Results in Asia # Of Countries HIV Positive SW SW Sample Size Pooled SW HIV Prevalence HIV Prevalence Women 15-49 Asia 14 3323642245.2%0.18% EE/FSU 4 331303710.9%0.2% LAC 12 627102736.1%0.38% MENA 5 179591.7%0.43% SSA 16 78992142136.9%7.42% Total501219799878 Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

9. HIV Prevalence among Asian FSW

10. Asia Meta-analysis

11. 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 3323642245.2%0.18% EE/FSU 4 331303710.9%0.2% LAC 12 627102736.1%0.38% MENA 5 179591.7%0.43% SSA 16 78992142136.9%7.42% Total501219799878 Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

12. HIV Prevalence among EE/FSU FSW

13. 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 3323642245.2%0.18% EE/FSU 4 331303710.9%0.2% LAC 12 627102736.1%0.38% MENA 5 179591.97%0.43% SSA 16 78992142136.9%7.42% Total501219799878 Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

14. HIV Prevalence among LAC FSW

16. 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 3323642245.2%0.18% EE/FSU 4 331303710.9%0.2% LAC 12 627102736.1%0.38% MENA 5 179591.7%0.43% SSA 16 78992142136.9%7.42% Total501219799878 Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0)

17. MENA HIV Prevalence among FSW

18. # Of Countries HIV Positive SW SW Sample Size Pooled SW HIV Prevalence HIV Prevalence Women 15-49 Asia 14 3323642245.2%0.18% EE/FSU 4 331303710.9%0.2% LAC 12 627102736.1%0.38% MENA 5 179591.7%0.43% SSA 16 78992142136.9%7.42% Total501219799878 Total HIV Prevalence among SW 11.8% (95% CI 11.6-12.0) Results in Sub-Saharan Africa

19. HIV Prevalence among SSA FSW

20. SSA FSW Meta-analysis

21. 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)

22. 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

23. 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

24. 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