title: Antiretroviral therapy uptake, attrition, adherence and outcomes among HIV-infected female sex workers: a systematic review and meta-analysis.
abstract: OBJECTIVE
  We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally.
  
  
  METHODS
  We systematically searched PubMed, Embase and MEDLINE in March 2014 to identify studies reporting on ART uptake, attrition, adherence, and outcomes (viral suppression or CD4 count improvements) among HIV-infected FSWs globally. When possible, available estimates were pooled using random effects meta-analyses (with heterogeneity assessed using Cochran's Q test and I2 statistic).
  
  
  RESULTS
  39 studies, reporting on 21 different FSW study populations in Asia, Africa, North America, South America, and Central America and the Caribbean, were included. Current ART use among HIV-infected FSWs was 38% (95% CI: 29%-48%, I2 = 96%, 15 studies), and estimates were similar between high-, and low- and middle-income countries. Ever ART use among HIV-infected FSWs was greater in high-income countries (80%; 95% CI: 48%-94%, I2 = 70%, 2 studies) compared to low- and middle-income countries (36%; 95% CI: 7%-81%, I2 = 99%, 3 studies). Loss to follow-up after ART initiation was 6% (95% CI: 3%-11%, I2 = 0%, 3 studies) and death after ART initiation was 6% (95% CI: 3%-11%, I2 = 0%, 3 studies). The fraction adherent to ≥95% of prescribed pills was 76% (95% CI: 68%-83%, I2 = 36%, 4 studies), and 57% (95% CI: 46%-68%, I2 = 82%, 4 studies) of FSWs on ART were virally suppressed. Median gains in CD4 count after 6 to 36 months on ART, ranged between 103 and 241 cells/mm3 (4 studies).
  
  
  CONCLUSIONS
  Despite global increases in ART coverage, there is a concerning lack of published data on HIV treatment for FSWs. Available data suggest that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings. More routine programme data on HIV treatment among FSWs across settings should be collected and disseminated.
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom.
authors.forename: Elisa
authors.initials: E
authors.lastname: Mountain
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom; Division of Infectious Diseases, St. Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada.
authors.forename: Sharmistha
authors.initials: S
authors.lastname: Mishra
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom.
authors.forename: Peter
authors.initials: P
authors.lastname: Vickerman
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom.
authors.forename: Michael
authors.initials: M
authors.lastname: Pickles
authors.affiliation: School of Population Health, University of Queensland, Brisbane, Australia.
authors.forename: Charles
authors.initials: C
authors.lastname: Gilks
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Boily
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000523:psychology; D006801:Humans; D010349:Patient Compliance; D011477:Sex Work
chemical_list: D019380:Anti-HIV Agents