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.
Highlights
By reducing HIV viral load and helping to restore immune function, antiretroviral therapy (ART) has led to substantial reductions in HIV-attributable mortality and morbidity and has greatly improved the quality of life for people living with HIV
Successful treatment can sustain viral suppression and lead to immunological improvement among those that are HIV-infected, but requires that individuals engage and remain in the HIV care cascade. This cascade involves a series of actions, starting with HIV screening/testing, and followed by linkage to HIV care after HIV diagnosis, retention in pre-ART care prior to ART initiation, initiation of ART once eligible for treatment, retention on treatment once ART is started, and maintenance of good ART adherence in order to achieve viral suppression and immunological improvement [7,8,9]
39 studies (Ns = 39) identified in the search were eligible to be included in our review (Figure 1), providing data on 21 independent female sex workers (FSWs) study populations (Np = 21) and at least 4,700 HIV-infected FSWs [22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60]
Summary
By reducing HIV viral load and helping to restore immune function, antiretroviral therapy (ART) has led to substantial reductions in HIV-attributable mortality and morbidity and has greatly improved the quality of life for people living with HIV. Evidence indicates that individuals on effective ART are less likely to transmit HIV [1,2,3,4,5] This evidence has sparked great interest in ART-based HIV prevention approaches, including ‘Treatment as Prevention’ (TasP), which aims to expand ART coverage among HIV-infected individuals in order to help reduce HIV transmission at a population level [6]. Successful treatment can sustain viral suppression and lead to immunological improvement among those that are HIV-infected, but requires that individuals engage and remain in the HIV care cascade. Evidence indicates that many individuals are lost at each stage of the cascade, and many individuals are diagnosed late, only initiating ART at the onset of symptoms [8,9,10,11]
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