Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis

Abstract

Background: Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa.

Methods: We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics.

Results: The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage.

Conclusions: The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.

Systematic review registration: PROSPERO CRD42020157623.

Keywords: Female sex workers; HIV care continuum; HIV interventions; HIV treatment cascade; Sub-Saharan Africa.

Fig. 1

PRISMA flow diagram of selection process

Fig. 2

Forest plots of quasi-experimental study with data on community-based interventions for HIV diagnosis

Fig. 3

Forest plots of RCT studies with data on community-based interventions for HIV diagnosis

Fig. 4

Forest plots of cross-sectional studies with data on community-based interventions for HIV diagnosis

Fig. 5

Forest plots of RCTs studies with data on community-based interventions for linkage to HIV care

Fig. 6

Forest plots of cross-sectional studies with data on community-based interventions for linkage to HIV care

Fig. 7

Forest plots of RCT studies with data on community-based interventions for ART use

Fig. 8

Forest plots of RCT studies at follow-up with data on community-based interventions for ART use

Fig. 9

Forest plots of cross-sectional studies with data on community-based interventions for ART use