Differentiating the incidence and burden of HIV by age among women who sell sex: a systematic review and meta‐analysis

Abstract

Introduction:Young women who sell sex (YWSS) are at heightened risk of HIV acquisition and transmission and are among the least engaged in HIV services. There is insufficient epidemiologic evidence characterizing the burden of HIV among YWSS, particularly as compared to older WSS. These data are needed to design and tailor effective HIV prevention and treatment programmes for this population. Methods: We conducted two parallel systematic reviews and meta-analyses to define both the immediate and long-term HIV risks for YWSS, including among women engaged in sex work, survival sex and transactional sex. In the first review, we identified and synthesized published studies of HIV incidence comparing estimates for cisgender women ≤24 years of age versus >24. In the second review, we identified and synthesized studies of HIV prevalence, comparing estimates for cisgender women who initiated selling sex <18 versus ≥18 years. In both reviews, we completed a search of four databases for articles in any language and any geographic area published from 1 January 1980 until 12 February 2021. Included articles were assessed for quality and a random effects model was used to calculate pooled effect estimates for each review. Results and Discussion: We identified 12 studies for the HIV incidence review and 18 studies for the HIV prevalence review. In a meta-analysis, HIV incidence was elevated in younger (5.3 per 100 person-years [PY]; 95% confidence interval [CI]: 3.5, 7.1) compared to older women (2.8 per 100 PY; 95% CI: 1.7, 3.9), although CIs overlapped. HIV prevalence among those who initiated selling sex <18 years of age (28.8; 95% CI: 18.9, 38.7) was higher than those who initiated later (20.5; 95% CI: 12.4, 28.6). Conclusions: These companion reviews offer an important perspective on the relative HIV risk of engaging in selling sex at a younger age. Our findings highlight the unique and intersectional challenges YWSS face, and the importance of ensuring that health services are tailored to meet their specific needs. Research and programming should routinely stratify data into meaningful age bands to differentiate and intervene within this population.

HIV incidence among women engaging in sex work in sub-Saharan Africa: a systematic review and meta-analysis

“… 98 Data from South Africa suggest that sex work dynamics are changing, with the mean age of sex workers and durations at-risk both increasing, 99 while young women who engage in sex work remain at highest incidence risk. 100 Different sampling and recruitment approaches are also likely to have identified different women for study inclusion. Studies have shown that participants recruited through respondent-driven sampling are younger than those recruited through venue-based snowball sampling.…”

HIV incidence among women engaging in sex work in sub-Saharan Africa: a systematic review and meta-analysis

“…33 Preliminary findings from South Africa suggest that sex work dynamics are changing with the mean age of sex workers increasing and longer durations at-risk, 34 whilst young WESW remain at highest incidence risk. 35 Different sampling and recruitment approaches were also likely to identify different women for study inclusion. Studies have shown that participants recruited through RDS are younger than those recruited through venue-based snowball sampling.…”

“…Data were insufficient to estimate pooled age-disaggregated IRRs which may have provided further insights, given evidence of higher incidence among younger WESW. 35 For all but one study which provided a comparator non-WESW group, 24 our IRR denominators were based on extrapolations of subnational estimates backwards in time parallel to national female incidence trajectories. Whilst this approach aimed to capture spatial variation over time, there is substantial uncertainty in these subnational incidence denominators, particularly for older studies, which is not reflected in the calculated IRRs.…”

Childhood and adolescent factors shaping vulnerability to underage entry into sex work: a quantitative hierarchical analysis of female sex workers in Nairobi, Kenya

“…was 24 years (IQR 20-28). Almost one-fifth (17.5%) of FSWs reported that they first began sex work before the age of 18 years, with the median age of sex work initiation in this group being 16 years (IQR 15-17), and the median age at which they were regularly selling sex being 18 years (IQR [16][17][18][19][20][21][22][23].…”

“…These adverse outcomes are often accompanied by stigma and discrimination, violence from official authorities, and barriers to healthcare 19. While some studies report an increased prevalence of HIV in adolescent girls and young women (AGYW) who initiate sex work under the age of 18 years compared with those who initiate sex work as adults,12 20 21 others find no significant difference in HIV prevalence between the two groups 9 10 21…”