Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis

BackgroundFemale 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 FindingsWe searched MEDLINE, Embase, and PsycINFO databases for studies published from January 1st, 2010 to February 10th, 2025 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 91 studies with 221 estimates, comprising 179,727 FSWs in 37 countries. We found higher odds of prevalent HIV infection among FSWs with recent (pooled odds ratio (pOR):1.33; 95%CI:1.17-1.51; I2:64%; n=73 estimates) and lifetime (pOR:1.36; 95%CI:1.24-1.49; I2:38%; n=67) experiences of violence. 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. ConclusionsExperiencing violence may increase HIV transmission risk and worsen HIV treatment outcomes among FSW. HIV interventions for FSWs must address violence as a structural determinant of HIV.