Antiretroviral Therapy Uptake, Attrition, Adherence and Outcomes among HIV-Infected Female Sex Workers: A Systematic Review and Meta-Analysis

Abstract

PurposeWe aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally.MethodsWe 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).Results39 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).ConclusionsDespite 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.

Test and treat: the early experiences in a clinic serving women at high risk of HIV infection in Kampala

“…Previously, we have seen how adherence changes over time (Mbonye, Nakamanya, Birungi, et al, 2013;; this may also be the case with this group, especially given the fact many start treatment without the strong motivation of those who started when they were already very ill or were aware that they had failing health. Although women, like those attending the clinic in Kampala, have been shown to be capable of adhering at comparable levels with other women in the general population (Mountain et al, 2014), barriers to adherence such as alcohol use, partner change, high mobility, stigma and poor disclosure are important factors in their lives that may affect their future on ART (Weiss et al, 2016).…”

Promise and pitfalls of pre-exposure prophylaxis for female sex workers

“…FSWs are less likely to be engaged in HIV prevention, treatment, and care services than women in the general population [4,62,63]. Although FSWs face the same barriers as other people [64][65][66][67], these barriers are compounded by anxiety about contact with authorities and concern about confidentiality, particularly that other FSWs or potential clients may learn their status [68].…”

Engagement in the HIV care cascade and barriers to antiretroviral therapy uptake among female sex workers in Port Elizabeth, South Africa: findings from a respondent-driven sampling study

“…In South Africa specifically, a recent systematic review found that there were no published estimates of engagement in the HIV care cascade among FSWs and initial reports of estimates of engagement in care are only beginning to emerge 12 13. Research and service provision for FSWs have lagged behind as sex work remains criminalised; however, the government-supported National Strategic Plan for HIV Prevention, Care and Treatment for Sex Workers was launched in 2013 and updated in 2016, with the objective to increase coverage and access to comprehensive HIV prevention, treatment and care 14 15.…”