Abstract

Background

Various interventions have been adopted to reduce HIV transmission among sex workers and their clients but the effectiveness of these strategies has yet to be investigated using meta‐analytic techniques.

Objectives

To evaluate the effectiveness of behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low‐ and middle‐income countries.

Search methods

The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane HIV/AIDS group specialized register, the Cochrane Database of Systematic Reviews, MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, Dissertation Abstract International (DAI), EMBASE, LILACS, BIOSIS, SciSearch, INDMED, Proquest, and various South Asian abstracting databases were included in the database list. The publication sites of the World Health Organization, the US Centers for Disease Control and Prevention, and other international research and non‐governmental organizations also appeared in the database list.

Selection criteria

Randomized controlled trials (RCTs) and quasi‐RCTs examining the effects on HIV transmission risk of different behavioral interventions or comparing behavioral interventions with no intervention, where described any one of the outcome measures, such as HIV incidence and prevalence, STI incidence and prevalence, change in self‐reported of condom use, and other HIV‐related outcome.

Data collection and analysis

Two authors independently assessed trials, extracted data and assessed the risk bias. Heterogeneity amongst trials was also tested.

Main results

A total of 13 trials with 8,698 participants were included. Primary outcomes (HIV and STI prevalence and incidence) were reported in seven trials. Of these, HIV incidence was reported in only three trials. After a 6‐month follow‐up assessment, there was no evidence that social cognitive behavioral intervention was effective in reducing HIV incidence (RR 0.12, 95% CI 0.01 to 2.22). However, there was a reduction in HIV incidence at 3‐month follow‐up assessment of promotion of female and male condom (RR 0.07, 95% CI 0.00 to 1.38). Social cognitive interventions and promotion of female and male condom use were significantly reduced STIs incidence (RR 0.57, 95% CI 0.34 to 0.96) and (RR 0.63, 95% CI 0.45 to 0.88), respectively. Secondary outcomes were identified in 13 trials. Meta‐analyses showed evidence that interventions to promote the use of female and male condoms do reduce non‐condom use (RR 0.83, 95% CI 0.65 to 1.05) compared to promotion of male condoms alone, and that social cognitive interventions reduced drug use among sex workers (RR 0.65, 95% CI 0.36 to 1.16) compared to standard care.

Authors' conclusions

Available evidence nevertheless suggests that compared with standard care or no intervention, behavioral interventions are effective in reducing HIV and the incidence of STIs amongst female sex workers (FSWs). Given the benefits of social cognitive theory and the promotion of condom use in reducing HIV/STI and the public health need to control transmission amongst FSWs, there is a clear finding in favour of behavioral interventions. However, it should be recognized that there is a lack of information about most other outcomes and target populations, and that all of the trials were conducted in low‐ and middle‐income countries.

Author(s)

Windy MV Wariki, Erika Ota, Rintaro Mori, Ai Koyanagi, Narumi Hori, Kenji Shibuya

Abstract

Plain language summary

Behavioral interventions to reduce HIV incidence and HIV/STI prevalence among female sex workers in low‐ and middle‐income countries

The rates of human immunodeficiency virus (HIV) and sexually transmitted infection (STI) transmission continue to increase, particularly among sex workers and their clients in low‐ and middle‐income countries. Prevention efforts directed towards these infections in this at‐risk population may have had an effect in reducing the overall transmission of HIV/STIs in the general population. Several successful behavioral interventions have been reported including interventions to reduce HIV/STI incidence and prevalence, change behavior, promote condom use, improve condom availability, and increase sexual health knowledge. The review found seven individual randomised controlled trials (RCTs), two cluster‐RCTs and four quasi‐RCTs involving 8,698 participants examining a variety of behavioral interventions to evaluate whether they reduced HIV/STIs rates or resulted in changed behavior among sex workers and their clients. Results showed that the interventions were effective in HIV/STI prevention, including reducing the incidence and prevalence of HIV and STIs. Furthermore, there were some differences in self‐reported behavior including increased condom use and a reduction in the risk of drug use. However, these trials were small and generally had few participants. As a result, evidence for the effectiveness of social cognitive theory and promoting condom use in reducing HIV/STI incidence compared to other behavioral interventions was limited, because no RCTs examined the effects of these interventions on HIV prevalence or on sex workers other than FSWs. In future research and program agendas therefore it is important to assess other potentially more potent behavioral change strategies.

Author(s)

Windy MV Wariki, Erika Ota, Rintaro Mori, Ai Koyanagi, Narumi Hori, Kenji Shibuya

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

HIV transmission among sex workers and their clients helps to drive a broader epidemic of heterosexually‐acquired HIV (UNAIDS 2009), resulting in transmission even among individuals who engage in low levels of risk behavior. Interventions to reduce the risk of HIV transmission amongst these high‐risk groups are therefore an important part of the international response to the HIV epidemic, and should be assessed carefully for their suitability, cost and effectiveness. This review strongly considers the effectiveness of several ongoing behavioral interventions that are likely to be available to policy makers and healthcare workers in low‐ and middle‐income nations. Policy makers, practitioners and researchers therefore have a greater range of choice of potential interventions to reduce HIV transmission risk among high‐risk groups. Before making a practice decision based on the current review, further information from other reviews considering how the role of combining sexual risk reduction, condom promotion and improved access to STI treatment reduces HIV and STI acquisition in sex workers receiving these interventions (Shahmanesh 2008) should to be taken into account. Nevertheless, given the observed effectiveness of social cognitive theory and the promotion of condom use in reducing transmission of HIV/STIs, and the clear need for a reduction in transmission, these behavioral interventions should be considered for implementation in high‐risk FSW communities in low‐ and middle‐income countries. This decision should be supported, however, by the knowledge that there is lack of information about most other outcomes and target populations, and although there is evidence in favour of their implementation amongst other high‐risk populations (such as transgender sex workers) the quality of this evidence is not currently sufficient to conclude that they will be effective amongst these populations. The studies reviewed here did not cover the full range of developing nations, but were spread across three continents and so be sufficient to inform policy‐makers from nations not represented in the current review. This review finds that the effects of some interventions were sustained in radically different national and local settings, indicating that the interventions be suitable in most low‐ and middle‐income countries.

Implications for research 

Researchers designing new RCTs in to measure intervention effects should strongly consider measuring HIV incidence and prevalence as outcomes, and assess risk‐factors for the spread of this infection. More high quality RCTs are urgently needed to further clarify which behavioral interventions are most effective in reducing the transmission of HIV among high‐risk, hidden or marginalized populations in low‐ and middle‐income countries. Moreover, because sub‐Saharan Africa remains the most heavily affected region of heterosexual transmission, including among sex workers, critical evaluation of interventions there should be conducted. Furthermore, the cost‐effectiveness of these interventions, particularly social cognitive behavioral interventions and the promotion of condom use as effective strategies targeted at vulnerable populations should be a priority area for research. Therefore, detailed data on the cost of interventions should be collected and analysed in a standardized format, and future implementation programs should consider enhanced study design and collection methods, to ensure that key findings from those studies are valid, generalizable and of high quality.

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