Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis
5 affiliations
- 1Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England
- 2Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
- 3Department of Family and Emergency Medicine, Faculty of Medicine, University of Montreal, Montreal, Canada
- 4Centre de recherche du Centre hospitalier de l’Université de Montréal, University of Montreal, Montreal, Canada
- 5Health Protection Research Unit, Bristol Medical School, University of Bristol, Bristol, England
Abstract
Background: Female sex workers (FSW) are a key population for HIV prevention and care. Increasing evidence suggests that social and structural barriers are key drivers of HIV transmission. This global systematic review assesses whether experiencing violence is associated with worse HIV outcomes among FSW.
Methods and findings: We searched MEDLINE, Embase, and PsycINFO databases for studies published from January 1st, 2010 to June 9th, 2026 assessing the impact of violence on HIV outcomes among FSW, without restriction to language and study design. Some studies had multiple estimates due to reporting on multiple outcomes or exposures of interest. We pooled data from eligible studies using multi-level random-effects meta-analyses to quantify associations between recent (past year) or lifetime exposure to violence (physical, sexual, emotional/psychological, and/or financial) and HIV outcomes (prevalent and incident HIV infection, HIV testing, ART use, ART adherence, and viral suppression) among FSW. We preferentially used adjusted estimates over unadjusted estimates if both were available.
We included 94 studies with 226 estimates, comprising 186,613 FSWs in 39 countries. Half the included studies were in low- and middle-income countries (n = 47, 50%), and one-fifth were in low-income countries (n = 18; 19%). We found higher odds of prevalent HIV infection among FSWs with recent (pooled odds ratio (pOR):1.31; 95% CI [1.16,1.48]; I2: 63%; n = 75 estimates) and lifetime (pOR:1.35; 95% CI [1.23,1.48]; I2: 39%; n = 68) experiences of violence. When stratifying violence by type, we found the strongest pooled associations between recent (pOR:1.55; 95% CI [1.24,1.94]; I2: 69%; n = 28) and lifetime (pOR:1.40; 95% CI [1.21,1.63]; I2: 47%; n = 28) experiences of sexual violence and HIV prevalence. Recently experiencing violence was associated with reduced odds of ART use (pOR:0.78; 95% CI [0.64,0.94]; I2: 8%; n = 17). Lifetime exposure to violence was associated with reduced odds of viral suppression (pOR:0.88; 95% CI [0.79,0.98]; I2: 20%; n = 6). There was no evidence of associations between violence and HIV incidence, HIV testing, and ART adherence.
Our study had limitations, notably the cross-sectional design of most included studies, the heterogeneity in pooled estimates, and the difficulties of measuring experiences of violence.
Conclusions: Experiencing violence is associated with greater odds of prevalent HIV infections, and poorer HIV treatment outcomes among FSWs. HIV interventions for FSWs must address violence as a structural determinant of HIV.
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BibTeX
@article{dawe2026impact,
title = {{Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis}},
author = {Joshua Dawe and Khadimul Anam Mazhar and Saher Aijaz Khan and Belinda Jackson Njiro and Victoria Bendaud and Keith Sabin and Julie Ambia and Adam Trickey and Lucy Barrass and Asra Asgharzadeh and Jack Stone and Adelina Artenie and Peter Vickerman},
journal = {PLOS Medicine},
year = {2026},
month = oct,
doi = {10.1371/journal.pmed.1004977},
url = {https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis
AU - Joshua Dawe
AU - Khadimul Anam Mazhar
AU - Saher Aijaz Khan
AU - Belinda Jackson Njiro
AU - Victoria Bendaud
AU - Keith Sabin
AU - Julie Ambia
AU - Adam Trickey
AU - Lucy Barrass
AU - Asra Asgharzadeh
AU - Jack Stone
AU - Adelina Artenie
AU - Peter Vickerman
PY - 2026
DA - 2026/10/21
JO - PLOS Medicine
DO - 10.1371/journal.pmed.1004977
UR - https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977
AB - Background: Female sex workers (FSW) are a key population for HIV prevention and care. Increasing evidence suggests that social and structural barriers are key drivers of HIV transmission. This global systematic review assesses whether experiencing violence is associated with worse HIV outcomes among FSW. Methods and findings: We searched MEDLINE, Embase, and PsycINFO databases for studies published from January 1st, 2010 to June 9th, 2026 assessing the impact of violence on HIV outcomes among FSW, without restriction to language and study design. Some studies had multiple estimates due to reporting on multiple outcomes or exposures of interest. We pooled data from eligible studies using multi-level random-effects meta-analyses to quantify associations between recent (past year) or lifetime exposure to violence (physical, sexual, emotional/psychological, and/or financial) and HIV outcomes (prevalent and incident HIV infection, HIV testing, ART use, ART adherence, and viral suppression) among FSW. We preferentially used adjusted estimates over unadjusted estimates if both were available. We included 94 studies with 226 estimates, comprising 186,613 FSWs in 39 countries. Half the included studies were in low- and middle-income countries (n = 47, 50%), and one-fifth were in low-income countries (n = 18; 19%). We found higher odds of prevalent HIV infection among FSWs with recent (pooled odds ratio (pOR):1.31; 95% CI [1.16,1.48]; I2: 63%; n = 75 estimates) and lifetime (pOR:1.35; 95% CI [1.23,1.48]; I2: 39%; n = 68) experiences of violence. When stratifying violence by type, we found the strongest pooled associations between recent (pOR:1.55; 95% CI [1.24,1.94]; I2: 69%; n = 28) and lifetime (pOR:1.40; 95% CI [1.21,1.63]; I2: 47%; n = 28) experiences of sexual violence and HIV prevalence. Recently experiencing violence was associated with reduced odds of ART use (pOR:0.78; 95% CI [0.64,0.94]; I2: 8%; n = 17). Lifetime exposure to violence was associated with reduced odds of viral suppression (pOR:0.88; 95% CI [0.79,0.98]; I2: 20%; n = 6). There was no evidence of associations between violence and HIV incidence, HIV testing, and ART adherence. Our study had limitations, notably the cross-sectional design of most included studies, the heterogeneity in pooled estimates, and the difficulties of measuring experiences of violence. Conclusions: Experiencing violence is associated with greater odds of prevalent HIV infections, and poorer HIV treatment outcomes among FSWs. HIV interventions for FSWs must address violence as a structural determinant of HIV.
SN - 1549-1676
SN - 1549-1277
ER -