Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in high‐income countries

Erika Ota; Windy MV Wariki; Rintaro Mori; Narumi Hori; Kenji Shibuya

doi:10.1002/14651858.CD006045.pub3

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: the review authors' judgements about each risk of bias item presented as percentages across all the included studies.

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Analysis 1.1

Comparison 1 Comparison intervention versus control, Outcome 1 STI incidence for sex workers.

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Analysis 1.2

Comparison 1 Comparison intervention versus control, Outcome 2 STI prevalence for clients of sex workers.

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Analysis 1.3

Comparison 1 Comparison intervention versus control, Outcome 3 Condom use for sex workers.

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Analysis 1.4

Comparison 1 Comparison intervention versus control, Outcome 4 Condom use for clients of sex workers.

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Analysis 1.5

Comparison 1 Comparison intervention versus control, Outcome 5 Knowledge of HIV transmission for sex workers.

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Analysis 1.6

Comparison 1 Comparison intervention versus control, Outcome 6 Knowledge of HIV transmission for clients of sex workers.

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Analysis 1.7

Comparison 1 Comparison intervention versus control, Outcome 7 Visited female sex workers (for clients of sex workers).

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Analysis 1.8

Comparison 1 Comparison intervention versus control, Outcome 8 Perceiving very high efficacy of condom use for HIV prevention (For clients of sex workers).

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Analysis 1.9

Comparison 1 Comparison intervention versus control, Outcome 9 physical victimization for sex workers.

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Analysis 1.10

Comparison 1 Comparison intervention versus control, Outcome 10 Sexual victimization for sex workers.

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Summary of findings for the main comparison. Behavioural intervention vs. control for reducing HIV transmission among sex workers and their clients in high‐income countries.

Behavioural intervention versus control for reducing HIV transmission among sex workers and their clients in high‐income countries.
Patient or population: Sex workers and their clients Settings: High‐income countries Intervention: Behavioural intervention versus control
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Comparison intervention versus control
STI incidence for sex workers	Study population		RR 0.46 (0.11 to 1.98)	627 (2 studies)	⊕⊝⊝⊝ very low^1,2,3,4
	302 per 1000	139 per 1000 (33 to 598)
	Moderate
	268 per 1000	123 per 1000 (29 to 531)
STI prevalence for clients of sex workers	Study population		RR 0.09 (0.01 to 0.72)	288 (1 study)	⊕⊕⊕⊕ high^3,5
	75 per 1000	7 per 1000 (1 to 54)
	Moderate
	75 per 1000	7 per 1000 (1 to 54)
Condom use for sex workers	Study population		RR 1.04 (0.99 to 1.09)	1133 (3 studies)	⊕⊝⊝⊝ very low^3,6
	825 per 1000	858 per 1000 (817 to 900)
	Moderate
	729 per 1000	758 per 1000 (722 to 795)
Condom use for clients of sex workers	Study population		RR 1.1 (0.69 to 1.75)	26 (1 study)	⊕⊕⊕⊝ moderate³
	706 per 1000	776 per 1000 (487 to 1000)
	Moderate
	706 per 1000	777 per 1000 (487 to 1000)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Not randomised studies. ² Heterogeneity is significantly different. ³ Small sample size. ⁴ RR is 0.46. ⁵ RR is 0.09. ⁶ Including non randomised studies.

Summary of findings for the main comparison. Behavioural intervention vs. control for reducing HIV transmission among sex workers and their clients in high‐income countries.

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Comparison 1. Comparison intervention versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 STI incidence for sex workers Show forest plot	2	627	Risk Ratio (M‐H, Random, 95% CI)	0.46 [0.11, 1.98]

2 STI prevalence for clients of sex workers Show forest plot	1	288	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.01, 0.72]

3 Condom use for sex workers Show forest plot	3	1133	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.99, 1.09]

3.1 Randomised control trial	1	506	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.96, 1.03]
3.2 Quasi‐experimental pretest‐posttest with control group	2	627	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.99, 1.18]
4 Condom use for clients of sex workers Show forest plot	1	26	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.69, 1.75]

5 Knowledge of HIV transmission for sex workers Show forest plot	1	381	Risk Ratio (M‐H, Fixed, 95% CI)	1.82 [1.55, 2.14]

6 Knowledge of HIV transmission for clients of sex workers Show forest plot	1	287	Risk Ratio (M‐H, Fixed, 95% CI)	1.93 [1.46, 2.55]

7 Visited female sex workers (for clients of sex workers) Show forest plot	1	286	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.25, 1.18]

8 Perceiving very high efficacy of condom use for HIV prevention (For clients of sex workers) Show forest plot	1	287	Risk Ratio (M‐H, Fixed, 95% CI)	1.35 [0.89, 2.04]

9 physical victimization for sex workers Show forest plot	1	506	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.63, 1.56]

10 Sexual victimization for sex workers Show forest plot	1	506	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.53, 1.86]

Comparison 1. Comparison intervention versus control

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