Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Cornell University, Qatar Foundation-Education City, P.O. Box 24144, Doha, Qatar.
Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
BMC Med. 2019 Jun 24;17(1):119. doi: 10.1186/s12916-019-1349-y.
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 < 1% in most countries, 1-5% in North Africa and Somalia, 17.3% in South Sudan, and 17.9% in Djibouti. Meta-regressions identified strong subregional variations in prevalence. Compared to Eastern MENA, the adjusted odds ratios (AORs) ranged from 0.2 (95% CI = 0.1-0.4) in the Fertile Crescent to 45.4 (95% CI = 24.7-83.7) in the Horn of Africa. There was strong evidence for increasing prevalence post-2003; the odds increased by 15% per year (AOR = 1.15, 95% CI = 1.09-1.21). There was also a large variability in sexual and injecting risk behaviors among FSWs within and across countries. Levels of HIV testing among FSWs were generally low. The median fraction of FSWs that tested for HIV in the past 12 months was 12.1% (range = 0.9-38.0%).
HIV epidemics among FSWs are emerging in MENA, and some have reached stable endemic levels, although still some countries have limited epidemic dynamics. The epidemic has been growing for over a decade, with strong regionalization and heterogeneity. HIV testing levels were far below the service coverage target of "UNAIDS 2016-2021 Strategy."
中东和北非（MENA）地区女性性工作者（FSW）及其客户的艾滋病毒流行病学情况了解甚少。我们通过全面的流行病学评估来解决这一差距。
按照 PRISMA 指南对人口规模估计和艾滋病毒流行率研究进行了系统评价，并进行了报告。使用各种质量领域的 Cochrane 合作指南提供的信息，对所有纳入的研究进行了偏倚风险（ROB）评估。使用随机效应荟萃分析估计了合并的平均艾滋病毒流行率。通过荟萃回归确定了异质性和时间趋势的来源。
我们在 FSW 中发现了 270 项规模估计研究和 42 项在客户中的研究，在 287719 名 FSW 和 69 名客户/代理人群中发现了 485 项艾滋病毒流行率研究。大多数研究在多个质量领域的 ROB 较低。报告当前/最近性工作的育龄妇女比例中位数为 0.6%（范围=0.2-2.4%），报告当前/最近购买性服务的男性比例中位数为 5.7%（范围=0.3-13.8%）。FSW 中的艾滋病毒流行率范围为 0 至 70%（中位数=0.1%），客户中的流行率范围为 0 至 34.6%（中位数=0.4%）。该地区的合并平均艾滋病毒流行率在 FSW 中为 1.4%（95%CI=1.1-1.8%），在客户中为 0.4%（95%CI=0.1-0.7%）。在大多数国家/地区，国家特定的合并流行率低于 1%，在北非和索马里为 1-5%，在南苏丹为 17.3%，在吉布提为 17.9%。荟萃回归确定了流行率的强烈次区域差异。与中东东部相比，调整后的优势比（AOR）范围从新月沃地的 0.2（95%CI=0.1-0.4）到非洲之角的 45.4（95%CI=24.7-83.7）。有强有力的证据表明 2003 年后流行率有所增加；每年增加 15%（AOR=1.15，95%CI=1.09-1.21）。FSW 之间和国家内部的性和注射风险行为也存在很大差异。FSW 进行艾滋病毒检测的水平普遍较低。在过去 12 个月内接受过艾滋病毒检测的 FSW 中位数为 12.1%（范围=0.9-38.0%）。
在 MENA，FSW 中的艾滋病毒流行正在出现，其中一些已经达到稳定的流行水平，尽管仍有一些国家的流行动态有限。该流行病已经持续了十多年，具有强烈的区域化和异质性。艾滋病毒检测水平远低于“UNAIDS 2016-2021 战略”规定的服务覆盖目标。
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