Abstract
BackgroundThe epidemiology of sexually transmitted infections (STIs) and the role of commercial heterosexual sex networks in driving STI transmission in the Middle East and North Africa (MENA) region remain largely unknown.ObjectiveTo characterize the epidemiology of Treponema pallidum (syphilis), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus type 2 (HSV-2) among female sex workers (FSWs) in MENA using an in-depth quantitative assessment.MethodsA systematic review on ten international, regional, and country-level databases was conducted, and reported following PRISMA guidelines. Pooled prevalences of current and/or ever infection for each STI were estimated using random-effects meta-analyses. Sources of between-study heterogeneity were investigated through random-effects meta-regressions.ResultsOne T. pallidum incidence study and 144 STI prevalence studies were identified for 45 812 FSWs in 13 MENA countries. The pooled prevalence of current infection was 12.7% (95% confidence interval (CI) = 8.5%-17.7%) for T. pallidum, 14.4% (95% CI = 8.2%-22.0%) for C. trachomatis, 5.7% (95% CI = 3.5%-8.4%) for N. gonorrhoeae, and 7.1% (95% CI = 4.3%-10.5%) for T. vaginalis. The pooled prevalence of ever infection (seropositivity using antibody testing) was 12.8% (95% CI = 9.4%-16.6%) for T. pallidum, 80.3% (95% CI = 53.2%-97.6%) for C. trachomatis, and 23.7% (95% CI = 10.2%-40.4%) for HSV-2. The multivariable meta-regression for T. pallidum infection demonstrated strong subregional differences, with the Horn of Africa and North Africa showing, respectively 6-fold (adjusted odds ratio (AOR): 6.4; 95% CI = 2.5-16.7) and 5-fold (AOR = 5.0; 95% CI = 2.5-10.6) higher odds of infection than Eastern MENA. There was also strong evidence for declining T. pallidum odds of infection at 7% per year (AOR = 0.93; 95% CI = 0.88-0.98). Study-specific factors including diagnostic method, sample size, sampling methodology, and response rate, were not associated with syphilis infection. The multivariable model explained 48.5% of the variation in T. pallidum prevalence.ConclusionsSTI infection levels among FSWs in MENA are considerable, supporting a key role for commercial heterosexual sex networks in transmission dynamics, and highlighting the health needs of this neglected and vulnerable population. Syphilis prevalence in FSWs appears to have been declining for at least three decades. Gaps in evidence persist for multiple countries.
Highlights
Correspondence to: Background The epidemiology of sexually transmitted infections (STIs) and the role of commercial heterosexual sex networks in driving STI transmission in the Middle East and North Africa (MENA) region remain largely unknown
One T. pallidum incidence study and 144 STI prevalence studies were identified for 45 812 female sex workers (FSWs) in 13 MENA countries
The pooled prevalence of current infection was 12.7% (95% confidence interval (CI) = 8.5%-17.7%) for T. pallidum, 14.4% for C. trachomatis, 5.7% for N. gonorrhoeae, and 7.1% for T. vaginalis
Summary
A systematic review on ten international, regional, and country-level databases was conducted, and reported following PRISMA guidelines. Pooled prevalences of current and/or ever infection for each STI were estimated using random-effects meta-analyses. We conducted a systematic review and an in-depth quantitative assessment to characterize STI epidemiology among FSWs in MENA. Evidence for syphilis, C. trachomatis, N. gonorrhaoeae, T. vaginalis, and HSV-2 immunoglobulin G (IgG) incidence and/or prevalence among FSWs in MENA was systematically reviewed, informed by Cochrane’s Collaboration guidelines [26]. Findings were reported following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [27] (checklist in Table S1 in Online Supplementary Document). Systematic searches were performed up to September 20, 2018, on international databases (PubMed and Embase), regional and national databases The MENA definition covers 23 countries—Afghanistan, Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates (UAE), and Yemen—based on convention in HIV research [19,20,24,25], and definitions of WHO, Joint United Nations Programme on HIV/AIDS (UNAIDS), and World Bank [24].
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