HIV epidemiology among female sex workers and their clients in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

HIV epidemiology among female sex workers (FSWs) and their clients in the Middle East and North Africa (MENA) region is poorly understood. We addressed this gap through a comprehensive epidemiological assessment. A systematic review of population size estimation and HIV prevalence studies was conducted and reported following PRISMA guidelines. Risk of bias (ROB) assessments were conducted for all included studies using various quality domains, as informed by Cochrane Collaboration guidelines. The pooled mean HIV prevalence was estimated using random-effects meta-analyses. Sources of heterogeneity and temporal trends were identified through meta-regressions. We identified 270 size estimation studies in FSWs and 42 in clients, and 485 HIV prevalence studies in 287,719 FSWs and 69 in 29,531 clients/proxy populations. Most studies had low ROB in multiple quality domains. The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range = 0.2–2.4%) and of men reporting currently/recently buying sex was 5.7% (range = 0.3–13.8%). HIV prevalence ranged from 0 to 70% in FSWs (median = 0.1%) and 0–34.6% in clients (median = 0.4%). The regional pooled mean HIV prevalence was 1.4% (95% CI = 1.1–1.8%) in FSWs and 0.4% (95% CI = 0.1–0.7%) in clients. Country-specific pooled prevalence was Other Information Published in: BMC Medicine License: http://creativecommons.org/licenses/by/4.0/See article on publisher's website: http://dx.doi.org/10.1186/s12916-019-1349-y</p

Viral non-suppression at follow-up by treatment group stratified according to baseline viral load.

Results are difference-in-difference of proportions in viral non-suppression between groups from baseline to follow-up.</p

Baseline characteristics of 579 participants with viral load testing at baseline and follow-up according to treatment group.

Baseline characteristics of 579 participants with viral load testing at baseline and follow-up according to treatment group.</p

Associations between baseline characteristics and completeness of viral load (VL) data presented as ORs with corresponding p-values from individual-level logistic regression analyses.

Associations between baseline characteristics and completeness of viral load (VL) data presented as ORs with corresponding p-values from individual-level logistic regression analyses.</p

Participants living with HIV and CMD recruited into the study between August 2017 and July 2018.

Participants living with HIV and CMD recruited into the study between August 2017 and July 2018.</p

Associations between baseline characteristics and treatment group (exposure) or viral non-suppression at endline (outcome) presented as ORs with corresponding p-values from individual-level logistic regression analyses.

Associations between baseline characteristics and treatment group (exposure) or viral non-suppression at endline (outcome) presented as ORs with corresponding p-values from individual-level logistic regression analyses.</p

Proportion of patients with viral non-suppression at baseline and six months follow-up by clinic.

Proportion of patients with viral non-suppression at baseline and six months follow-up by clinic.</p

Inclusivity in global research.

BackgroundFor people living with co-morbid HIV and common mental disorders (CMD), it is not known whether a brief psychological intervention for CMD can improve HIV viral suppression.MethodsWe conducted a prospective cohort study in eight primary care clinics in Harare, Zimbabwe, enrolling adults with co-morbid HIV and CMD. Six clinics provided the Friendship Bench (FB), a brief psychological intervention for CMD based on problem-solving therapy, delivered by lay counsellors. Two clinics provided enhanced usual care (EUC). The primary outcome was viral non-suppression after six months (viral load ≥400 copies/mL). Data were analysed using a difference-in-difference approach with linear regression of cluster-level proportions, adjusted for baseline viral non-suppression (aDiD). The secondary outcome was presence of CMD measured by the Shona Symptom Questionnaire.ResultsIn FB clinics, 407/500 (81.4%) participants had viral load results at baseline and endline: 58 (14.3%) had viral non-suppression at baseline and 41 (10.1%) at endline. In EUC clinics, 172/200 (86.0%) had viral load results at baseline and endline: 22 (12.8%) were non-suppressed at baseline and 26 (15.1%) at endline (aDiD = -7.3%; 95%CI 14.7% to -0.01%; p = 0.05). Of the 499 participants virally suppressed at baseline, the FB group had lower prevalence of non-suppression at endline compared to the EUC group (2.9% vs 9.3%; p = 0.002). There was no evidence of a difference in endline viral non-suppression by group among the 80 participants with non-suppression at baseline (53.5% vs 54.6%; p = 0.93). The FB group was less likely to screen positive for CMD at endline than the EUC group (aDiD = -21.6%; 95%CI -36.5% to -6.7%; p = 0.008).ConclusionPeople living with co-morbid HIV and CMD may benefit from receiving a low-cost mental health intervention to enhance viral suppression, especially if they are already virally suppressed. Research is needed to understand if additional adherence counselling could further improve viral suppression.</div

Association of treatment group with mental health using cluster-level analysis adjusted for the respective baseline value.

Results are adjusted DiD of proportions (binary outcomes) or in means (continuous outcomes) between treatment groups from baseline to follow-up.</p

Multivariable logistic regression–associations with HIV status.

Multivariable logistic regression–associations with HIV status.</p