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

Abstract

Background: Women who engage in sex work in sub-Saharan Africa have a high risk of acquiring HIV infection. HIV incidence has declined among all women in sub-Saharan Africa, but trends among women who engage in sex work are poorly characterised. We synthesised data on HIV incidence among women who engage in sex work in sub-Saharan Africa and compared these with the total female population to understand relative incidence and trends over time.

Methods: We searched MEDLINE, Embase, Global Health, and Google Scholar from Jan 1, 1990, to Feb 28, 2024, and grey literature for studies that reported empirical estimates of HIV incidence among women who engage in sex work in any sub-Saharan Africa country. We calculated incidence rate ratios (IRRs) compared with total female population incidence estimates matched for age, district, and year, did a meta-analysis of IRRs, and used a continuous mixed-effects model to estimate changes in IRR over time.

Findings: From 32 studies done between 1985 and 2020, 2194 new HIV infections were observed among women who engage in sex work over 51 490 person-years. Median HIV incidence was 4·3 per 100 person years (IQR 2·8-7·0 per 100 person-years). Incidence among women who engage in sex work was eight times higher than matched total population women (IRR 7·8 [95% CI 5·1-11·8]), with larger relative difference in western and central Africa (19·9 [9·6-41·0]) than in eastern and southern Africa (4·9 [3·4-7·1]). There was no evidence that IRRs changed over time (IRR per 5 years: 0·9 [0·7-1·2]).

Interpretation: Across sub-Saharan Africa, HIV incidence among women who engage in sex work remains disproportionately high compared with the total female population. However, constant relative incidence over time indicates HIV incidence among women who engage in sex work has declined at a similar rate. Location-specific data for women who engage in sex work incidence are sparse, but improved surveillance and standardisation of incidence measurement approaches could fill these gaps. Sustained and enhanced HIV prevention for women who engage in sex work is crucial to address continuing inequalities and ensure declines in new HIV infections.

Funding: Bill & Melinda Gates Foundation, UK Research and Innovation, National Institutes of Health.

Translation: For the French translation of the abstract see Supplementary Materials section.

Figure 1

Trial profile WESW=women who engage in sex work. *Full texts meeting criteria include multiple papers reporting on the same study. †All papers identified in the preliminary search were identified in the updated review. Individual studies identified are the primary texts from which data were extracted from.

Figure 2

Empirical estimates of HIV Incidence among women who engage in sex work Association between HIV incidence in WESW and in the district-year-sex matched total population (A) and empirical estimates of HIV incidence in WESW over time (B). Black dashed line represents the line of equality. WESW=women who engage in sex work.

Figure 3

Meta-analysis of HIV incidence in women who engage in sex work relative to the total female population in sub-Saharan Africa IRRs calculated by dividing empirical estimates of HIV incidence in women who engage in sex work by HIV incidence among total population of women matched for age, district, and year derived from the district-level estimation model Naomi, and synthesised by use of meta-analysis with study-district random effects. Figure shows year of data collection, country, and study.

Figure 4

HIV IRRs modelled over time, presented on the logarithmic scale Points represent IRRs calculated by dividing study-reported HIV incidence in WESW by age–district–year matched total population HIV incidence derived from the Naomi model. The solid line represents the estimated IRR for sub-Saharan Africa, with the grey shading capturing the 95% uncertainty range. IRR=incidence rate ratio. WESW=women who engage in sex work.