title: Data and methods to characterize the role of sex work and to inform sex work programs in generalized HIV epidemics: evidence to challenge assumptions.
abstract: In the context of generalized human immunodeficiency virus (HIV) epidemics, there has been limited recent investment in HIV surveillance and prevention programming for key populations including female sex workers. Often implicit in the decision to limit investment in these epidemic settings are assumptions including that commercial sex is not significant to the sustained transmission of HIV, and HIV interventions designed to reach "all segments of society" will reach female sex workers and clients. Emerging empiric and model-based evidence is challenging these assumptions. This article highlights the frameworks and estimates used to characterize the role of sex work in HIV epidemics as well as the relevant empiric data landscape on sex work in generalized HIV epidemics and their strengths and limitations. Traditional approaches to estimate the contribution of sex work to HIV epidemics do not capture the potential for upstream and downstream sexual and vertical HIV transmission. Emerging approaches such as the transmission population attributable fraction from dynamic mathematical models can address this gap. To move forward, the HIV scientific community must begin by replacing assumptions about the epidemiology of generalized HIV epidemics with data and more appropriate methods of estimating the contribution of unprotected sex in the context of sex work.
authors.affiliation: Division of Infectious Diseases, Department of Medicine, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada; Department of Infectious Disease Epidemiology, Imperial College, London, UK.
authors.forename: Sharmistha
authors.initials: S
authors.lastname: Mishra
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College, London, UK.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Boily
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
authors.forename: Sheree
authors.initials: S
authors.lastname: Schwartz
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
authors.forename: Chris
authors.initials: C
authors.lastname: Beyrer
authors.affiliation: Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.
authors.forename: James F
authors.initials: JF
authors.lastname: Blanchard
authors.affiliation: Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.
authors.forename: Stephen
authors.initials: S
authors.lastname: Moses
authors.affiliation: Office of HIV/AIDS, United States Agency for International Development, Washington, DC.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: HIV/AIDS, STI, and Tuberculosis Department, Human Sciences Research Council, Port Elizabeth, South Africa.
authors.forename: Nancy
authors.initials: N
authors.lastname: Phaswana-Mafuya
authors.affiliation: School of Social and Community Medicine, Bristol University, Bristol, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Vickerman
authors.affiliation: Department of Geography, Université Gaston-Berger, St. Louis, Senegal.
authors.forename: Fatou
authors.initials: F
authors.lastname: Drame
authors.affiliation: Département de médecine sociale et préventive, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada.
authors.forename: Michel
authors.initials: M
authors.lastname: Alary
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD. Electronic address: sbaral@jhu.edu.
authors.forename: Stefan D
authors.initials: SD
authors.lastname: Baral
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D003140:Communicable Disease Control / Q000379:methods*; D019317:Evidence-Based Medicine; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000635:transmission*; D006293:Health Promotion / Q000458:organization & administration; D006801:Humans; D008962:Models, Theoretical; D020380:Needs Assessment; D015995:Prevalence; D018570:Risk Assessment; D060386:Sex Workers; D012725:Sexual Behavior; D047568:Unsafe Sex / Q000706:statistics & numerical data*
keywords: Generalized HIV epidemics; HIV; Mathematical models; Population attributable fraction; Sex work; Sub-Saharan Africa