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Try out PMC Labs and tell us what you think. Learn More. Although female sex workers are known to be vulnerable to HIV infection, little is known about the epidemiology of HIV infection among this high-risk population in the United States. We systematically identified and critically assessed published studies reporting HIV prevalence among female sex workers in the United States. We searched for and included original English-language articles reporting data on the prevalence of HIV as determined by testing at least 50 females who exchanged sexual practices for money or drugs.

We did not apply any restrictions on date of publication. We included 14 studies from to that reported HIV prevalence for a total of adult female sex workers. Only two of the 14 studies were conducted in the last 10 years. The pooled estimate of HIV prevalence was Very few studies have documented the prevalence of HIV among female sex workers in the United States; however, the available evidence does suggest that HIV prevalence among this vulnerable population is high.

Based on the latest available data, the rate of diagnosis for HIV infection among women in the United States decreased from 9. However, there may be subgroups among the female population where HIV transmission remains high, such as female sex workers. Globally, sex workers are among the populations most affected by HIV. A systematic review of HIV infection among female sex workers in developing countries found an overall prevalence of A recent update to this systematic review included additional data from to and showed that the estimated prevalence varied widely by region from 0.

The estimated HIV prevalence in high income countries was 1. Despite extensive research [ 4 — 6 ] and ongoing HIV surveillance among female sex workers internationally [ 7 ], there have been few studies among this high-risk population in the United States and our understanding of the burden of HIV among them is limited. Behavioral studies from the United States and around the world have often found several sources of risk among female sex workers.

For example, female sex workers often have large s of sex partners, concurrency of partners, report infrequent or inconsistent condom use, and are likely to engage in high-risk sexual acts such as condomless anal sex [ 8 — 13 ]. Data from the continental United States and Puerto Rico show that sex workers are more likely than other women to have a history of sexually transmitted infections STI [ 14 — 16 ], and STI contribute to increased likelihood of acquiring and transmitting HIV [ 17 ].

Studies from the United States have also documented a high prevalence of injection and non-injection drug use among women who engage in exchange sex [ 18 , 19 ]. Not surprisingly, female sex workers who inject drugs are at higher risk of HIV infection when compared to female sex workers who do not inject drugs since they can acquire HIV through sex without condoms and through sharing needles or other injection equipment. Women who abuse drugs or alcohol may feel more pressure to have condomless sex if offered more money or drugs by their clients.

They may also trade sex while under the influence and receive less money when selling sex [ 20 ]. Structural risk factors for HIV infection include work environment, poverty, stigma, discrimination, and criminalization of sex work which increase the risk for HIV infection among sex workers by creating barriers to accessing HIV care and prevention services [ 5 , 18 , 21 — 25 ].

The settings where sex work occurs have a large impact on vulnerability by making it harder to negotiate condom use, find protection from violence, and have access to HIV prevention, treatment and sexual health services, including STI treatment, condoms and contraception [ 26 ]. For example, a study in Kenya found that street-based sex workers had a higher prevalence of HIV when compared to women working in fixed establishments [ 27 ].

In Miami, sex workers did not seek healthcare out of fear of discrimination and arrest [ 25 ]. Finally, there are important barriers associated with accessing prevention services as a result of the anti-prostitution laws in 49 of 50 states in the United States. Federal and local policies may discourage researchers and programs from providing services to this population [ 28 ]. The findings of systematic reviews have improved characterization of HIV burden in other parts of the world and in populations who are most at risk for HIV, including men who have sex with men, transgender women and female sex workers in international settings [ 3 , 29 , 30 ].

To date, however, no systematic reviews of the burden of HIV among female sex workers in the United States have been published and the burden of HIV among this population remains poorly understood. The purpose of this systematic review is to characterize the prevalence of, and risk factors for, HIV infection among female sex workers in the United States.

Other electronic bibliographic databases were then searched separately using parallel, database specific syntax. Citations for identified articles were imported into a central bibliographic database where deduplication was performed.

Full-length copies of all articles meeting these retrieval criteria were obtained. For quality control purposes, ten percent of articles were randomly evaluated by a second reviewer. In addition to searches of electronic bibliographic databases, hand searches were also performed. We retrieved items that appeared to potentially meet inclusion criteria based on title and abstract see box. All retrieved full-length articles were evaluated for inclusion in the evidence base against a list of inclusion criteria independently by two trained reviewers.

A third reviewer facilitated article reassessment and discussion to resolve conflicts. In summary, we included English-language articles with original relevant quantitative data on the prevalence of HIV collected from a sample of at least 50 female sex workers in the United States.

We defined sex work as exchanging sex for money, drugs, or goods. We only included articles that determined HIV infection using diagnostic tests for HIV antibodies using blood or oral specimens. We verified these criteria were satisfied when we reviewed full-length articles and ensured no duplicate data same data reported in more than one article were extracted by comparing authors, dates of data collection, study location, and sample size.

When we did identify duplicate data, we selected the publication with the largest sample size, more complete reporting or which was most recent. This review used secondary data available publicly with no interaction with human subjects. Consequently, no ethics review was necessary or conducted. Data were extracted onto standardized forms by a single experienced research analyst and all entries were audited for accuracy by a second author. We extracted and assessed HIV prevalence estimates from all included studies as if they were descriptive, cross-sectional studies.

Two of the included studies had longitudinal experimental des intended to assess other outcomes [ 18 , 33 ] and one was an observational cohort study [ 8 ]; from these, we collected baseline HIV prevalence data. We critically evaluated each included study to assess the likelihood that the prevalence estimates reported might be biased using the Joanna Briggs Institute critical appraisal tool for prevalence studies [ 34 ].

The criteria in the tool assess the following issues: representativeness, recruitment, sample size, description and reporting of study subjects and setting, data coverage of the identified sample, condition measured reliably and objectively, statistical analysis, and confounding factors. In order to estimate a weighted-mean estimate of prevalence across all included studies, prevalence estimates reported by each study were pooled using a random-effects meta-analysis model [ 35 ]. A random effects model was chosen because the characteristics of the sex workers and work settings differed considerably across included studies.

As a consequence, we did not expect that the prevalence estimates would be homogeneous. Homogeneity was tested using both I 2 and the Q-statistic [ 36 , 37 ]. Tests of homogeneity assess whether differences between studies included in a meta-analysis can be explained by chance alone.

We attempted to explain heterogeneity using an unrestricted maximum likelihood mixed effects meta-regression analysis [ 38 ]. Covariates considered in these exploratory analyses included: injection drug use; sex with injection drug users; any drug use; anal sex; condom use; age; of sex partners; duration of sex work; race; ethnicity.

To assess the robustness of our findings, we performed a series of sensitivity analyses [ 39 , 40 ]. These sensitivity analyses included an influence analysis removing one study from the meta-analysis at a time to assess whether any single study was particularly influential in contributing to the overall summary prevalence estimate. All meta-analysis and meta-regression was performed using Comprehensive Meta-Analysis 3. Our searches identified a total of potentially relevant articles.

Of these, 57 met our retrieval criteria and 14 met our inclusion criteria Fig. Three included studies were not prevalence studies. Study selection process, systematic review of HIV prevalence among female sex workers in the United States. Key characteristics of included studies, systematic review of HIV prevalence among female sex workers in the United States. Eight studies exclusively enrolled sex workers; the rest assessed sub-populations of sex workers drawn from samples of studies of other populations such as persons who use drugs, high-risk individuals and low income residents of selected neighborhoods.

Only two studies were conducted in the last 10 years. As evidenced by Table 1 , reporting on the characteristics of study participants was extremely limited which restricted our ability to generalize the findings of the included studies. Where individual characteristics data were available, it was clear that the characteristics of the female sex workers in the included studies varied widely. Most included studies reported little to no information on potential factors associated with HIV prevalence.

The duration of employment in sex work was typically not reported, but in the two studies that did report on this, the duration ranged widely from a few months to more than a decade [ 41 , 42 ]. Sexual practices sold Table 1 were reported by only three studies, which reported that women sold predominantly vaginal sex, oral sex, or both [ 16 , 41 , 43 ]. Only half of the studies reported the setting were sex work occurred Table 1.

The prevalence of any drug use among enrollees in the included studies was high; however, in some studies, women were selected for study participation specifically because they were drug users [ 8 , 18 , 33 , 43 , 44 ]. The findings of our quality assessment and the way criteria were evaluated are summarized in Table 2 items 1 through As noted above, most of the included studies were deed to measure the prevalence of HIV among female sex workers in the various cities throughout the United States.

In the three longitudinal studies we used the reported prevalence among female sex workers at baseline. Of most importance to the quality of the studies included in this systematic review is the size of the study, its generalizability and the confidence one has in the measurement of key outcomes such as HIV prevalence. While all participants included in the evidence base were female sex workers, the degree to which their demographics and HIV risk behaviors are representative of female sex workers in the United States is unclear.

This lack of clarity is due to limited reporting of basic information that describes the characteristics of enrollees as well as lack of information that characterizes the underlying population. This situation is further exacerbated by the age of the included studies only two of studies were conducted in the last 10 years , and the limited geographic coverage of the included studies. Only two of the studies included in the present evidence base used probabilistic or pseudo-probabilistic sampling methods cluster sampling [ 14 ] and respondent driven sampling [RDS] [ 47 ].

The sampling methods used are described for each study in Table 1 and primarily included convenience samples. Individuals recruited in this manner may not be representative of the population of female sex workers in the participating cities.

No studies described the process to estimate sample size. We calculated the sample size required to provide a reasonable estimate of HIV prevalence. Only three of the 14 studies had a sample size of or greater. Most studies did not report key variables such as demographics, HIV risk factors i. Only five studies reported all the variables listed above.

Eleven studies reported injection drug use. A total of eight studies met this criterion, two did not meet it and data on percent tested was not reported for four. All included studies conducted laboratory testing to diagnose HIV infection. Three studies did not specify the testing strategy and one conducted testing with an oral fluid test without confirmation. Oral tests are known to have low sensitivity compared to blood based tests. The primary objective of this review was to determine prevalence and then use meta-regression and sub-group analyses to explore differences among studies and generate adjusted estimates as appropriate.

For statistical analyses of convenience samples we only required that studies report the of participants with a positive HIV test and the total of individuals in the sample. For probability samples we required for the studies to conduct weighted analyses. Of the two probability-sampling studies, only one conducted weighted analysis.

A total of 6 reported HIV prevalence by sub-group. Although membership in these sub-populations was based on self-reported data that suffer from social desirability bias and recall bias, self-report is the standard to collect behavioral information.

The incidence of HIV among female sex workers in the United States was reported by only one dated study. Among women, the study reported that incidence increased from 12 per person-years in — to 19 per person-years in [ 48 ]. The prevalence of HIV among female sex workers in the United States was reported by all 14 included studies. Reported prevalence ranged from a low of 0. The pooled prevalence was The prevalence estimates obtained from the 14 included studies and the resulting pooled prevalence are shown in Fig. This figure is ordered from the study with the lowest top of figure to the highest prevalence to emphasize the extent of the variation in reported prevalence.

Exploration of the observed heterogeneity in prevalence estimates observed across the 14 included studies was hampered by poor reporting which limited our ability to explore associations between potentially important covariates Table 1. Indeed, reporting of the characteristics of the included women and details of the sex practices they employed was so sparse that meta-regression was only possible for one covariate in only a subset of studies: the proportion of female sex workers with a history of injection drug use [ 8 , 14 , 41 , 42 , 44 — 46 , 49 ].

Three additional studies reported injection drug use only in the last 30 days [ 33 , 50 ] or 6 months [ 18 ] and were not included in this analysis. Further analyses aimed at examining the association between year when the study was conducted and HIV prevalence found no evidence of an association between HIV prevalence and data collection year or year of publication.

The HIV prevalence estimate was not statistically ificantly different between the two studies that collected data in the last 10 years An influence analysis in which one study was removed from the analysis at a time suggests that no single study was particularly influential in the overall summary estimate, which suggests that the studies with very high or very low HIV prevalence did not skew the overall finding.

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