Risk factor for hiv

HIV can affect anyone regardless of sexual orientation, race, ethnicity, gender or age. However, certain groups are at higher risk for HIV and merit special consideration because of particular risk factors.

Is the Risk of HIV Different for Different People?

Some groups of people in the United States are more likely to get HIV than others because of many factors, including the status of their sex partners, their risk behaviors, and where they live.

When you live in a community where many people have HIV infection, the chances of having sex or sharing needles or other injection equipment with someone who has HIV are higher. You can use CDC’s HIV, STD, hepatitis, and tuberculosis Atlas Plus to see the percentage of people with HIV (“prevalence”) in different US communities. Within any community, the prevalence of HIV can vary among different populations.

Gay and bisexual men have the largest number of new diagnoses in the United States. Blacks/African Americans and Hispanics/Latinos are disproportionately affected by HIV compared to other racial and ethnic groups. Also, transgender women who have sex with men are among the groups at highest risk for HIV infection, and injection drug users remain at significant risk for getting HIV.

Risky behaviors, like having anal or vaginal sex without using a condom or taking medicines to prevent or treat HIV, and sharing needles or syringes play a big role in HIV transmission. Anal sex is the highest-risk sexual behavior. If you don’t have HIV, being a receptive partner (or bottom) for anal sex is the highest-risk sexual activity for getting HIV. If you do have HIV, being the insertive partner (or top) for anal sex is the highest-risk sexual activity for transmitting HIV.

But there are more tools available today to prevent HIV than ever before. Choosing less risky sexual behaviors, taking medicines to prevent and treat HIV, and using condoms with lubricants are all highly effective ways to reduce the risk of getting or transmitting HIV. Learn more about these and other strategies to prevent HIV.

Learn More About Groups at Risk for HIV

For more information about the risk for different groups of people, see U.S. Statistics, Impact on Racial and Ethnic Minorities, and CDC’s HIV by Geographical Distribution. For more information about groups at risk for HIV, visit CDC’s Groups at Risk page.

Learn more about how to protect yourself, and get information tailored to meet your needs from CDC’s HIV Risk Reduction Tool (BETA).

Factors Increasing the Risk of Acquiring or Transmitting HIV

Acute HIV Infection

Population HIV Risk Estimate Source Interpretation
Heterosexual Men and Women 7.25 Wawer, 2015 The risk of HIV transmission during acute infection is about 7.25 times the risk during the middle stage of HIV disease among heterosexual men and women.
MSM 7.25 Wawer, 2015 There are no empirical data providing a direct estimate for MSM. It is biologically plausible for acute infection to have a similar effect on HIV transmission among MSM.

The risk of HIV transmission during acute infection is about 7.25 times the risk during the middle stage of HIV disease among MSM.

Strengths and Limitations of Risk Estimates:

  • Wawer, 2015 estimates the increased risk of HIV transmission due to acute HIV infection from a retrospective sub-sample of 235 monogamous, HIV-discordant heterosexual couples with follow up time from a larger Rakai (Uganda) community-randomized trial of STD control for AIDS prevention. This study looked at early-stage infection (defined as up to 5 months after seroconversion, a 2.5-month midpoint), established infection or “middle” stage of infection (>6 months after seroconversion), and late-stage infection (6 to 25 months before death).
  • No other published study of empirical data on increased risk of HIV transmission during acute infection exists.
  • Acute HIV infection is clinically defined as the time between viral infection and development of detectable antibodies against HIV-1. During this time, concentrations of HIV in blood and semen are highest and transmission risk is therefore greatest; this period typically last a few weeks (Cohen, 2005; Pilcher, 2004). Pilcher, 2007 estimated that viral load reaches its peak at 17 days after seroconversion in blood and around 4 weeks after seroconversion in semen. A modeling paper (Pilcher, 2004) estimated the probability of heterosexual transmission of HIV during acute infection is ~8 to10 times the probability during later stage of infection, where the viral load peak in semen was modeled at about day 20 after infection.
  • Although no direct empirical evidence has been identified for MSM at this time, acute infection is likely to also be associated with increased HIV transmission risk among MSM. The estimate for heterosexual men and women is the best proxy estimate for MSM until more direct evidence is available.

Source:

  • Cohen MS & Pilcher CD. Amplified HIV transmission and new approaches to HIV prevention. J Infect Dis 2005;191:1391-3.
  • Pilcher CD, Tien HC, Eron JJ Jr, et al. Quest Study, Duke-UNC-Emory Acute HIV Consortium. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis 2004; 189(10):1785–92.
  • Pilcher CD, Joaki G, Hoffman IF, et al. Amplified transmission of HIV-1: comparison of HIV-1 concentrations in semen and blood during acute and chronic infection. AIDS 2007;21(13):1723-30.
  • Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis 2005;191:1403-9.

HIV/AIDS

The human immunodeficiency virus (HIV) targets the immune system and weakens people’s defence systems against infections and some types of cancer. As the virus destroys and impairs the function of immune cells, infected individuals gradually become immunodeficient. Immune function is typically measured by CD4 cell count.

Immunodeficiency results in increased susceptibility to a wide range of infections, cancers and other diseases that people with healthy immune systems can fight off.

The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS), which can take from 2 to 15 years to develop if not treated, depending on the individual. AIDS is defined by the development of certain cancers, infections or other severe clinical manifestations.

Signs and symptoms

The symptoms of HIV vary depending on the stage of infection. Though people living with HIV tend to be most infectious in the first few months after being infected, many are unaware of their status until the later stages. In the first few weeks after initial infection people may experience no symptoms or an influenza-like illness including fever, headache, rash or sore throat.

As the infection progressively weakens the immune system, they can develop other signs and symptoms, such as swollen lymph nodes, weight loss, fever, diarrhoea and cough. Without treatment, they could also develop severe illnesses such as tuberculosis (TB), cryptococcal meningitis, severe bacterial infections, and cancers such as lymphomas and Kaposi’s sarcoma.

Transmission

HIV can be transmitted via the exchange of a variety of body fluids from infected people, such as blood, breast milk, semen and vaginal secretions. HIV can also be transmitted from a mother to her child during pregnancy and delivery. Individuals cannot become infected through ordinary day-to-day contact such as kissing, hugging, shaking hands, or sharing personal objects, food or water.

Risk factors

Behaviours and conditions that put individuals at greater risk of contracting HIV include:

  • having unprotected anal or vaginal sex;
  • having another sexually transmitted infection (STI) such as syphilis, herpes, chlamydia, gonorrhoea and bacterial vaginosis;
  • sharing contaminated needles, syringes and other injecting equipment and drug solutions when injecting drugs;
  • receiving unsafe injections, blood transfusions and tissue transplantation, and medical procedures that involve unsterile cutting or piercing; and
  • experiencing accidental needle stick injuries, including among health workers

Diagnosis

HIV can be diagnosed through rapid diagnostic tests that provide same-day results. This greatly facilitates early diagnosis and linkage with treatment and care. People can also use HIV self-tests to test themselves. However, no single test can provide a full HIV diagnosis; a confirmatory test is required, conducted by a qualified and validated health worker at a community centre or clinic. HIV infection can be detected with great accuracy using WHO prequalified tests within a nationally approved testing strategy.

Most widely-used HIV diagnostic tests detect antibodies produced by the person as part of their immune response to fight HIV. In most cases, people develop antibodies to HIV within 28 days of infection. During this time, people experience the so-called “window” period – when HIV antibodies haven’t been produced and when they may have had no signs of HIV infection, but also when they may transmit HIV to others. After infection, an individual may transmit HIV transmission to a sexual or drug-sharing partner.

Following a positive diagnosis, people should be retested before they are enrolled in treatment and care to rule out any potential testing or reporting error. Notably, once a person diagnosed with HIV and has started treatment they should not be retested.

While testing for adolescents and adults has been made simple and efficient, this is not the case for babies born to HIV-positive mothers. For children less than 18 months of age, serological testing is not sufficient to identify HIV infection – virological testing must be provided as early as birth or at 6 weeks of age). New technologies are now becoming available to perform this test at the point of care and enable same-day results, which will accelerate appropriate linkage with treatment and care.

HIV testing services

HIV testing should be voluntary and the right to decline testing should be recognized. Mandatory or coerced testing by a health care provider or authority, or by a partner or family member is not acceptable as it undermines good public health practice and infringes on human rights.

New technologies to help people test themselves are being introduced, with many countries implementing self-testing as an additional option to encourage HIV diagnosis. HIV self-testing is a process whereby a person who wants to know his or her HIV status collects a specimen, performs a test, and interprets the test results in private or with someone they trust. HIV self-testing does not provide a definitive HIV-positive diagnosis, but it should be used as an initial test to be followed by confirmatory testing by a health worker.

The sexual partners and drug-injecting partners of people diagnosed with HIV infection have an increased probability of also being HIV-positive. WHO recommends assisted HIV partner notification services as a simple and effective way to reach these partners – many of whom are undiagnosed and unaware of their HIV exposure and may welcome support and an opportunity to test for HIV.

All HIV testing services must follow the WHO-recommended principles known as the “5 Cs”:

  • informed Consent
  • Confidentiality
  • Counselling
  • Correct test results
  • Connection (linkage to care, treatment and other services).

Prevention

Individuals can reduce the risk of HIV infection by limiting exposure to risk factors. Key approaches for HIV prevention, which are often used in combination, are listed below.

Male and female condom use

Correct and consistent use of male and female condoms during vaginal or anal penetration can protect against the spread of STIs, including HIV. Evidence shows that male latex condoms have an 85% or greater protective effect against HIV and other STIs.

Testing and counselling for HIV and STIs

Testing for HIV and other STIs is strongly advised for all people exposed to any of the risk factors. This enables people to learn of their own HIV status and access necessary prevention and treatment services without delay. WHO also recommends offering testing for partners or couples. Additionally, WHO recommends assisted partner notification approaches, in which people with HIV receive support to inform their partners either on their own, or with the help of health care providers.

Testing and counselling, linkages to tuberculosis (TB) care

TB is the most common illness among people living with HIV. Fatal if undetected or untreated, TB is the leading cause of death among people with HIV, responsible for nearly 1 in 3 HIV-associated deaths.

Early detection of TB and prompt linkage to TB treatment and ART can prevent these deaths. TB screening should be offered routinely at HIV care services, and routine HIV testing should be offered to all patients with presumptive and diagnosed TB. TB preventive therapy should be offered to all people living with HIV who do not have active TB. Individuals who are diagnosed with HIV and active TB should urgently start effective TB treatment (including for multidrug-resistant TB) and ART.

Voluntary medical male circumcision (VMMC)

Medical male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Since 2007, WHO recommends VMMC as an additional prevention strategy. This is a key prevention intervention supported in 15 countries in eastern and southern Africa with high HIV prevalence and low male circumcision rates. VMMC is also regarded as a good approach to reach men and adolescent boys who do not often seek health care services. At the end of 2018, 23 million adolescent boys and men in eastern and southern Africa had been provided with a package of services, including VMMC, HIV testing, and education on safer sex and condom use.

Use of ARVs for prevention

Prevention benefits of ART

A scientific trial confirmed that if an HIV-positive person adheres to an effective ART, the risk of transmitting the virus to their uninfected sexual partner can be reduced by 96% in 2011. Following the results, WHO recommended that all people living with HIV should be offered ART with the aim of saving lives and significantly reducing HIV transmission. A 2019 study showed that HIV transmission risk through sex without condoms in serodiscordant men in same sex couples who were virally suppressed and on ART was effectively zero.

Pre-exposure prophylaxis (PrEP) for HIV-negative partner

Oral PrEP of HIV is the daily use of ARVs by HIV-negative people to block the acquisition of HIV. More than 10 randomized controlled studies have demonstrated the effectiveness of PrEP in reducing HIV transmission among a range of populations, including serodiscordant heterosexual couples (where one partner is infected and the other is not), men who have sex with men, transgender women, high-risk heterosexual couples, and people who inject drugs.

WHO recommends PrEP as a prevention choice for people at substantial risk of HIV infection as part of a combination of prevention approaches. WHO has also expanded these recommendations to HIV-negative women who are pregnant or breastfeeding.

Post-exposure prophylaxis for HIV (PEP)

PEP is the use of ARVs within 72 hours of exposure to HIV to prevent infection. PEP includes counselling, first aid care, HIV testing, and administration of a 28-day course of ARV drugs with follow-up care. WHO recommends PEP use for both occupational and non-occupational exposures, and for adults and children.

Harm reduction for people who inject and use drugs

People who inject drugs can take precautions against becoming infected with HIV by using sterile injecting equipment (including needles and syringes) for each injection, and not sharing drug-using equipment and drug solutions. Treatment of drug dependence, in particular, opioid substitution therapy for people dependent on opioids, also helps to reduce the risk of HIV transmission and supports adherence to HIV treatment. A comprehensive package of HIV prevention and treatment interventions for people who inject drugs includes:

  • needle and syringe programmes;
  • opioid substitution therapy for people dependent on opioids, and other evidence-based drug dependence treatment;
  • HIV testing and counselling;
  • HIV treatment and care;
  • risk-reduction information and education, and provision of naloxone to prevent opioid overdose;
  • access to condoms; and
  • management of STIs, TB and viral hepatitis.

Elimination of mother-to-child transmission of HIV

The transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is called vertical or mother-to-child transmission (MTCT). In the absence of any interventions during these stages, rates of HIV transmission from mother-to-child can be between 15% and 45%. The risk of MTCT can almost be eliminated if both the mother and her baby are provided with ARV drugs as early as possible in pregnancy and during the period of breastfeeding.

WHO recommends lifelong ART for all people living with HIV, regardless of their CD4 count and the clinical stage of disease; this includes pregnant and breastfeeding women. In 2018, 82% of the estimated 1.3 million pregnant women living with HIV globally received ARV drugs to prevent transmission to their children. A growing number of countries and territories are achieving very low rates of MTCT, with some formally validated for elimination of MTCT of HIV as a public health problem (Anguilla, Antigua and Barbuda, Armenia, Belarus, Bermuda, Cayman Islands, Cuba, Malaysia, Maldives, Montserrat, Saint Kitts and Nevis, and Thailand). Several countries with a high burden of HIV infection are also progressing along the path to elimination.

Treatment

HIV can be suppressed by combination ART consisting of 3 or more ARV drugs. ART does not cure HIV infection but suppresses viral replication within a person’s body and allows an individual’s immune system to strengthen and regain the capacity to fight off infections.

In 2016, WHO recommended that all people living with HIV be provided with lifelong ART, including children, adolescents and adults, and pregnant and breastfeeding women, regardless of clinical status or CD4 cell count. By mid-2019, 182 countries had already adopted this recommendation, covering 99% of all people living with HIV globally.

  • WHO updated its HIV treatment guidelines in 2018 and 2019 to reflect the latest scientific advances.

The HIV treatment guidelines include new alternative ARV options with better tolerability, higher efficacy, and lower rates of treatment discontinuation when compared with previous recommended medicines. WHO recommends the use of dolutegravir-based or low-dose efavirenz for first-line therapy, and raltegravir and darunavir/ritonavir for second-line therapy.

Transition to dolutegravir has already started in 82 low- and middle-income countries and is expected to improve the durability of the treatment and the quality of care for people living with HIV. Despite improvements, limited options remain for infants and young children. For this reason, WHO and partners are coordinating efforts to enable a faster and more effective development and introduction of age-appropriate paediatric formulations of ARV drugs.

In addition, 1 in 3 people living with HIV present to care with advanced disease, at low CD4 counts, and at high risk of serious illness and death. To reduce this risk, WHO recommends that these individuals receive a “package of care” that includes testing for and prevention of the most common serious infections that can cause death, such as TB and cryptococcal meningitis, in addition to ART.

Globally, 23.3 million people living with HIV were receiving ART in 2018. This equates to a global ART coverage rate of 62%. However, more efforts are needed to scale up treatment, particularly for children and adolescents. Only 54% of children and adolescents were receiving ART at the end of 2018.

Expanding access to treatment is at the heart of a set of targets for 2020, which aim to bring the world back on track to end the AIDS epidemic by 2030.

WHO response

The Sixty-Ninth World Health Assembly endorsed a new “Global health sector strategy on HIV for 2016–2021”. The strategy includes five strategic directions that guide priority actions by countries and by WHO over six years.

The strategic directions are:

  • Information for focused action (know your epidemic and response)
  • Interventions for impact (covering the range of services needed)
  • Delivering for equity (covering the populations in need of services)
  • Financing for sustainability (covering the costs of services)
  • Innovation for acceleration (looking towards the future).

WHO is a cosponsor of the Joint United Nations Programme on AIDS (UNAIDS). Within UNAIDS, WHO leads activities on HIV treatment and care, and HIV and TB coinfection, and jointly coordinates the work on elimination of MTCT of HIV with UNICEF.

  • Global health sector strategy on HIV, 2016-2021

Introduction

The number of individuals infected with human immunodeficiency virus (HIV-1) continues to increase worldwide. Based on the latest statistics, there are nearly 40 million HIV-positive people in the world, while the developing countries contain 95% of them.1 It is estimated that 14 thousand individuals are being infected with the HIV each day worldwide and more than 30 million people have lost their lives because of the AIDS, since the first HIV positive patient was identified. Many studies suggested that the most common mode of HIV transmission is associated with sexual affairs and relationships in the US; while, in Eastern Europe, especially Ukraine and Central Asia, intravenous drug use has been reported as the main mode of transmission.2,3 Moreover, more than half of the HIV-positive individuals were identified to be female. Intravenous illegal drug use and unprotected sex contribute as the main risk factors for HIV transmission among this group.4,5 However, various social, economic, and political factors can also further affect the prevalence of HIV/AIDS.6 For instance; the main source of HIV infection in developed countries such as the UK and the US is homosexuality, while high-risk sexual relationships (including polygamy, having intercourse with sex workers, and unprotected sexual relationships) in African countries and intravenous drug use in Eastern and Southeastern countries mainly contributed to the transmission of HIV.7–10 Several studies have indicated high levels of HIV prevalence among female sex workers (FSW) who earn money in exchange for providing sexual services to their clients.11 Compared with the general population, it seems that FSW are more susceptible to ADIS due to the different factors of unprotected sexual intercourse, sex with multiple partners, and other probable high risk sexual relationships.12

Moreover, as is expected, FSW can extremely transmit HIV/AIDS. Thus, providing and implementing educational and interventional policies as well as preventive programs targeting this group could greatly reduce the prevalence of HIV/AIDS within different societies.12

Over the past two decades remarkable successes have been achieved in reducing the risk of contamination with HIV, as well as the associated morbidity, mortality, and stigma, and indisputable improvements have been made in the quality-of-life of people living with HIV.13 In this regard, the Joint United Nations has also developed a Program on HIV/AIDS (UNAIDS) with the approach to diagnose 90% of all HIV-positive individuals, provide antiretroviral treatments (ART) for 90% of diagnosed persons, and to attain viral suppression for 90% of treated individuals by 2020. It is believed that this could result in viral suppression in at least 73% of infected people, which is a necessary step in order to end the AIDS epidemic by 2030.2 However, according to the recent reports by the national HIV program, it is indicated that the 90–90–90 targets agenda is unrealistic for 2020.14 About 2.1 million new HIV-positive cases were diagnosed in 2015, and such a high rate of incidence can further fuel the epidemics of this disease.

Since the treatment course of the disease and providing supportive care are difficult, highly costed, and complicated, the most important and feasible strategy could be the implementation of preventative measures such as education, counseling, and changing behavioral patterns.15 To achieve this goal, knowledge about the modes of disease transmission and awareness of target groups who are more vulnerable to AIDS or the groups who are mostly involved in the disease prevalence and other risk factors is needed. Thus, in the present study we aimed to determine HIV/AIDS prevalence rates in FSW, as well as to study the related risk factors from 2010 to 2017 by a systematic review of literature and meta-analysis approach.

Research method

Data sources and search strategy

The international databases of ISI Web of Science, Embase, PubMed, and Scopus were searched carefully to find English language studies which reported the HIV/AIDS prevalence and its associated risk factors among FSW between the years of 2010 and 2017. The searches were done using the appropriate keywords of HIV/AIDS, immunodeficiency, risk factors, sex workers, and female sex workers (FSW), along with all possible word combinations. Moreover, additional manual searches were performed using reference lists of relevant articles to find further papers which may be missed in the electronic searching process.

Study selection (inclusion and exclusion criteria)

All cross-sectional and descriptive or group studies investigating the relationship between each or a group of risk factors and HIV/AIDS prevalence were considered in order to review their full texts. We examined the selected articles for relevance in three phases of title, abstract, and full text review. The main inclusion criterion for this study was relevance for “HIV/AIDS prevalence and associated risk factors among FSWs”. Also, the studies with inadequate information, investigations other than descriptive research, review studies, abstracts published in congresses, non-English language published articles, systematic studies, meta-analyzes, and repeated investigations (duplications) were excluded from data analysis (Table 2). For all of the selected research articles, the data were extracted on name of the first author, the year of publication, study context, sample size, continent and the country of origin, and HIV/AIDS prevalence based on each of the risk factors (Table 1). Two of the authors searched for all the relevant articles and then provided a list of abstracts upon completion of the search. At this stage, 234 potentially relevant articles on the HIV/AIDS prevalence and its associated risk factors among FSW were entered into the initial list. Afterwards, all the research articles were individually reviewed; and 76 of them were excluded because of being duplicates. Another 90 papers were also excluded because they were published before 2010. Moreover, 14 articles were omitted due to the inaccessibility of their full text, and 17 studies were excluded because they were found to be meta-analyses and review articles rather than original publications. Finally, 37 research articles were selected to be eligible to enter into this meta-analysis (Figure 1).

Table 1 Demographic characteristics of studies involved in meta-analysis

Table 2 The initial data on the prevalence of AIDS based on risk factors in the articles entered in the meta-analysis

Figure 1 Prisma flow diagram illustrating selection of articles. Note: 14 articles were omitted due to the inaccessibility of their full text.

Data extraction

The 37 articles were selected as most relevant and high-quality studies for this meta-analysis. Then, a checklist of necessary information was provided for all the studies. The checklist contained information on the different items needed for the study (the name of the first author, year of the publication, study context, sample size, a variety of risk factors, HIV/AIDS prevalence rate, etc.).

Statistical analysis

In order to calculate the variance of each study and the combination of HIV/AIDS prevalence and its risk factors in FSWs, binomial distribution and weighted mean were used, respectively. Thus, each study was weighted in accordance with its variance. Given the large differences in the HIV prevalence within the different studies (the heterogeneity of research articles) and significance of the heterogeneity index (I2), a random effects model was employed in this meta-analysis. We used metaprop command in STATA to perform random effects meta-analysis (meta-analysis of proportions) and calculate the pooled estimate of proportions with the corresponding 95% confident intervals. Moreover, the Freeman-Tukey Double Arcsine Transformation (Freeman, M. F., and Tukey, J. W. 1950) was used to stabilize the variances when the proportions were close to 0 or 1. Metaprop requires two variables in the format {n, N} such that P=n/N to be declared.

Findings

In this meta-analysis, we examined 37 eligible original articles on HIV/AIDS prevalence among FSWs published from 2010 to 2017, encompassing a total number of 46,657 FSWs. The overall findings showed that HIV/AIDS prevalence among FSWs was equal to 8%. But, after sensitivity analysis and deletion of outlier studies, the prevalence rate of HIV among FSWs was found to be 2.17 (95% CI=1.37–3.14) (Figure 2).

Figure 2 The prevalence of HIV among sex workers based on the random effects model. The midpoint of each section estimates the prevalence and length of the line, the 95% confidence interval in each study, and the diamond shows the prevalence of HIV among sex workers in this study.

Figure 3 The prevalence of condom use in sex with clients by sex workers based on the random effects model. The midpoint of every line estimates the prevalence in each study, and the diamond shows the overall prevalence for all study.

Figure 4 The prevalence of injecting drug use in sex workers based on the random effects model. The midpoint of each section of the line estimated prevalence in each study, and the diamond indicates the prevalence of injecting drug use for all studies.

Publication bias

The Begg’s funnel plot was used to assess the presence of publication bias in the studies. To this end, the studies were sorted from the most precise to the least precise (according to standard error), and then a cumulative random effect meta-analysis was run to realize if there was any trivial change in effect size (Figure 5). Trim and fill analysis was done as well to check the effects of missing studies on the overall results and adjust the final pooled effect size.

Figure 5 Begg’s funnel plot for publication bias.

Discussion

FSW have been considered as the most important group for HIV/AIDS transmission and propagation within societies; however, associated risk factors and the prevalence of HIV among this population have not been systematically evaluated in the past decade. In the present study, the overall HIV/AIDS prevalence among FSWs between 2010 and 2017 was obtained to be 2.17 (95% CI=1.37–3.14). The highest rate of HIV/AIDS prevalence among FSWs was reported as 38% by Vandepitte et al16 in Uganda. However, no HIV-positive individual was identified among FSW in the studies conducted by Mahfoud et al17 in Lebanon and Kang et al18 in China; the lowest HIV/AIDS prevalence among this group. Recently, antiretroviral therapy (ART) has been shown to be able to induce a high remission rate among HIV positive individuals. In this regard, it has been strongly confirmed that ART could result in desirable outcomes both in treatment and prevention of HIV by; 1) improving the health condition of individuals who already diagnosed with HIV and 2) preventing the ongoing HIV transmissions.20,21 In accordance, universal coverage of ART was recommended for all HIV positive patients by WHO. However, our results showed a different pattern of HIV prevalence among FSW within different countries. According to these findings, we assumed that the preventive measures and treatment procedures should be applied context-specific and in compliance with national approaches to combat with HIV.19

Due to the criminal nature of sex work, a limited number of researches have developed on this subject and no special services are provided for FSW. To address this issue, the South African National AIDS Council, in 2013, launched the strategy of the National Strategic Plan for HIV Prevention, Care, and Treatment for Sex Workers, and it was updated in 2016 to provide more comprehensive coverage and access to anti-HIV treatments.22,23

In recent years, the HIV/AIDS new cases were most widely found among FSW in Africa.16,24–26 Also, the same results were obtained in the meta-analysis study conducted by Baral et al,27 who investigated the incidence of HIV/AIDS among FSWs in low-income countries. They found that the prevalence rate of the HIV/AIDS among FSWs in 50 low-income countries was equal to 11.8%, which was higher than the prevalence rate obtained in the present study. The discrepancy between these results may be explained by higher exposure to HIV/AIDS, as well as the poor educational and preventive measures implemented to combat HIV in low-income nations.

Previously, Zhang et al28 investigated the prevalence of HIV/AIDS among FSWs across the six regions in China during 2000–2011 using meta-analysis. Their findings revealed that the prevalence of HIV/AIDS among FSWs has declined from 0.74% in 2000 to 0.40% with 95% confidence interval in 2011. Zhang et al28 assumed that this declining trend may potentially be associated with interventional efforts and HIV prevention programs implemented in the country. According to the results of the present study and the study conducted by Zhang et al,28 it is obvious that the HIV/AIDS prevalence among FSW of Asian countries is relatively low.

Moreover, a study conducted by Chow et al,29 showed that comprehensive behavioral interventions were more effective, rather than health education only programs, to improve condom use and HIV testing uptake among FSW in China. According to their result, behavioral interventions improved condom use among FSW by 2.3–5.0-times compared with the pre-intervention period. Also, they found that behavioral intervention has resulted in a 4.6-fold HIV testing uptake among FSW in the past 12 months. Such a comprehensive intervention program has also raised the awareness of FSW on the HIV transmission modes, as well preventive measures they should take to avoid probable HIV exposure. Our results indicate the high rate of intravenous drug use among FSW (0.07%) as an important risk factor for HIV transmission. Besides, infrequent use of condoms during their sexual intercourse with clients was also recognized as another important risk factor which makes them vulnerable to be infected with HIV.

Conclusion

The present study showed the high prevalence rate of HIV infection among FSWs. We assumed that FSW could act as a core group in HIV/AIDS transmission and propagation due to the high frequency as well as daily sexual relationships with different partners. Moreover, two important risk factors of infrequent condom use and prevalence of intravenous drug use among FSW highlights their role in HIV/AIDS transmission more than ever. Hence, comprehensive and global interventional programs need to be implemented to reduce the prevalence of HIV/AIDS among FSW and to prevent HIV propagation in societies.

One of the important limitations in this domain was the lack of access to some relevant studies, and some studies were not published in English. Unfortunately, it seems that the prevalence rate of HIV among FSW may be higher than that reported in the present study and in other studies, because the criminal nature of sex work in some countries as well as the Taboo make the results somehow unrealistic.

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