title: Global epidemiology of HIV among female sex workers: influence of structural determinants.
abstract: Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.
authors: Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada. Electronic address: kshannon@cfenet.ubc.ca.
authors: Kate
authors: K
authors: Shannon
authors: University of California San Diego School of Medicine, San Diego, CA, USA.
authors: Steffanie A
authors: SA
authors: Strathdee
authors: Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada.
authors: Shira M
authors: SM
authors: Goldenberg
authors: Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada.
authors: Putu
authors: P
authors: Duff
authors: Bar Hostesses Empowerment and Support Program, African Sex Workers Alliance, Nairobi, Kenya.
authors: Peninah
authors: P
authors: Mwangi
authors: Stellit NGO, St Petersburg, Russia.
authors: Maia
authors: M
authors: Rusakova
authors: Ashodaya Samathi Collective, Mysore, India.
authors: Sushena
authors: S
authors: Reza-Paul
authors: Chinese University of Hong Kong, China.
authors: Joseph
authors: J
authors: Lau
authors: Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada.
authors: Kathleen
authors: K
authors: Deering
authors: Imperial College, London, UK.
authors: Michael R
authors: MR
authors: Pickles
authors: Imperial College, London, UK.
authors: Marie-Claude
authors: MC
authors: Boily
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D002170:Canada / Q000453:epidemiology; D017280:Condoms / Q000706:statistics & numerical data; D005260:Female; D014943:Global Health / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D007194:India / Q000453:epidemiology; D007630:Kenya / Q000453:epidemiology; D015995:Prevalence; D012307:Risk Factors; D011477:Sex Work / Q000706:statistics & numerical data*; D060386:Sex Workers / Q000706:statistics & numerical data*
chemical_list: D044966:Anti-Retroviral Agents