PrEP among female sex workers: where are we? A literature review identifying knowledge gaps to guide the future research agenda
Mélanie Plazy, Valentine Becquet, Esther Maouhoub, Carla Meertens, Rémi Mouquin, Hasna Youssoufa, Marcellin Nouaman, Patrick Coffie, Joseph Larmarange
Objectives. In 2015, the WHO recommended HIV pre-exposure prophylaxis (PrEP) for people at substantial risk of being infected by HIV, but also highlighted the need for research projects to improve PrEP implementation and follow-up, especially among female sex workers (FSW). While many studies have been published on PrEP among men who have sex with men, the literature is far less important among FSW. We aim to summarise the overall published literature on PrEP among FSW worldwide to display the challenges and facilitators of PrEP implementation in this population and highlight the knowledge gaps.
Methods. We have conducted a systematic literature review searching Pubmed, Web of Sciences, Scopus, SocINDEX, APA PsycArticles, APA PsycInfo, Psychology and Behavioral Sciences Collection, until 31 December 2022. All manuscripts on PrEP in FSW were included worldwide, regardless of the primary outcome, the type of PrEP (oral, topical or long-acting), the study design, or the type of data collection. Titles and abstracts were independently screened by three reviewers, and full texts by two reviewers. We excluded papers: not presenting specific or stratified results on FSW; study protocols; conference abstracts; not written in English or French. Two independent reviewers then reviewed each included study to extract: Unaids region, country, study type, outcomes (see description in the results), type of PrEP, and study years. The results of the included papers will be analysed in more detail by one reviewer for each type of outcome.
Results. Among the 412 published references identified through the search equation after duplicate removal, 198 were excluded based on the title and abstract, and 69 were excluded after full-text reading. Among the 145 papers included, n=10 were commentaries, n=17 literature reviews on global HIV prevention or including several populations, n=3 country case studies, n=24 modelling studies and n=91 other original papers. Among the latest, n=51 studies were conducted in Eastern and Southern Africa, n=13 in Western and Central Africa, n=11 in Asia and the Pacific, n=9 in Western and Central Europe and North America, n=7 in Latin America and the Caribbean; no studies were conducted in the Middle East and North Africa or Eastern Europe and Central Asia. The majority (n=85) were about oral PrEP. Regarding outcomes, n=39 were on knowledge/awareness, n=42 on willingness/interest, n=38 on attitudes/perceptions/beliefs, n=42 on uptake/use, n=21 on retention, n=23 on adherence, n=4 on efficacy/effectiveness, n=3 on epidemiological impacts, n=18 on behavioural impacts, n=5 on social impacts, n=10 on delivery models, n=9 on costs. Specific results for each type of outcome is in progress. Preliminary results suggest high PrEP willingness among FSW, but specific challenges regarding oral PrEP uptake and retention in this population.
Discussion. The overall literature on PrEP focusing on FSW is relatively scarce (compared to more than 1850 references on PrEP among men who have sex with men identified on Pubmed by the end of 2022). The final results of this literature review will be available by May 2023. They will allow to guide the future research agenda regarding the implementation of biomedical HIV prevention among FSW.