Review of the Epidemiology of HIV among Sex Workers 23
The comparison of HIV prevalence among female sex workers and rates among all women are conservative given that HIV infections are included in the estimates provided by UNAIDS for all reproductive age women. To address this, sensitivity analysis was completed removing infections among reproductive age women attributable to female sex workers and then completing the meta-analysis. The magnitude of the global pooled estimate did not change though it did in certain countries where a high proportion of HIV among women is attributable to sex work. While the pooled analysis is limited related to the heterogeneity estimates by country, it does have utility in demonstrating the continued disease burden among female sex workers, and their continued need for services. A recent report on the investment framework for the global AIDS response suggested that current levels of resource allocation for sex workers was adequate (Schwartlander, Stover et al. 2011). This analysis, contextualized by evidence that female sex workers living with HIV have more partners than other reproductive age women living with HIV and higher rates of STIs facilitating HIV transmission, suggests that more resources are needed to address these sub-epidemics (Brahmam, Kodavalla et al. 2008; Bautista, Pando et al. 2009; Chohan, Baeten et al. 2009; Kang, Liao et al. 2011). This synthesis highlights that 50 countries out of 145 low and middle income countries have published data including a biological assessment of HIV prevalence among female sex workers in the last 5 years (World 2009). In other words, approximately two thirds of low and middle income countries (65.5%, n=95/145) do not have a current estimate of the burden of HIV among female sex workers. There are several potential explanations for these data gaps including social stigma, criminalization of sex work, and the aforementioned “Prostitution Pledge” which conflated the issue of sex work and human trafficking and markedly reduced research funding and investigator interest in this area (Masenior and Beyrer 2007). These findings suggest an urgent need to scale up access to quality HIV prevention programming and services among female sex workers secondary to their heightened burden of disease and likelihood of onward transmission through high numbers of sexual partners as clients. Given the high burden of HIV among female sex workers and recent biomedical advances related to treatment as prevention it is also critical to improve linkages to anti-retroviral treatment and retention in care and ongoing prevention for female sex workers living with HIV (Cohen, Chen et al. 2011). The dramatically increased odds of living with HIV among sex workers merits continued research regarding the role of not only behavioral but also structural factors associated with HIV