HIV and Other Sexually Transmitted Infections Among Female Sex Workers in Iran: A Systematic Review and Meta-Analysis
Given the high burden of HIV and other sexually transmitted infections (STIs) among female sex workers (FSW) and their potential role in bridging HIV/STIs into the general population, estimating the prevalence of HIV/STIs among FSW is essential for future research and policy developments. This systematic review and meta-analysis synthesize the available HIV/STIs data among FSW in Iran. We searched MEDLINE, PsycINFO, CINAHL, Embase, Web of Science, Google Scholar, and Iranian databases from inception through to January 2018. Inclusion criteria were original quantitative studies that measured HIV/STIs prevalence among FSW. Pooled prevalence estimates were calculated using random-effects meta-analyses. Out of a total of 299 screened studies, 12 were included with total study participants of 4328 FSW. Heterogeneity was present but meta-regression analyses revealed no significant association between HIV prevalence and year of publication, city, and age. Pooled HIV prevalence was 2.23% (95% confidence interval [CI] 0.82, 3.64). We estimated the prevalence of other STIs as 0.77% (95% CI 0.01, 1.53) for hepatitis B, 6.18% (95% CI 1.32, 11.04) for hepatitis C, 0.33% (95% CI 0.00, 0.66) for syphilis, 1.47% (95% CI 0.22, 2.71) for gonorrhea, 9.80% (95% CI 4.70, 14.91) for chlamydia, and 6.18% (95% CI 4.92, 7.43) for trichomonas vaginalis. Based on the existing evidence, HIV and STIs prevalence among FSW are relatively low in Iran. Strategies for timely diagnosis and treatment of HIV and other STIs among FSW and their sexual and injecting partners are needed to reduce the burden of HIV/STIs among these vulnerable populations in Iran.
KeywordsFemale Sex Workers Human Immunodeficiency Virus Sexually Transmitted Infections Meta-analysis Iran
Mohammad Karamouzian is supported by the Vanier Canada Graduate Scholarship (Vanier CGS) and the Pierre Elliott Trudeau Doctoral Scholarship.
All authors contributed to the study conception and design. A literature search was performed by MK and SG. Data analysis was performed by MK, MN, and AM. The first draft of the manuscript was written by MK and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Authors received no funding for conducting this study.
Compliance with Ethical Standards
Conflict of interest
Authors declare that they have no conflict of interest.
This study used secondary data and no ethical approval was not required.
Not Applicable (given the nature of the study).
- Abu-Raddad, L. J., Hilmi, N., Mumtaz, G., Benkirane, M., Akala, F. A., Riedner, G., & Wilson, D. (2010). Epidemiology of HIV infection in the Middle East and North Africa. AIDS,24(Suppl. 2), S5–S23. https://doi.org/10.1097/01.aids.0000386729.56683.33.CrossRefPubMedGoogle Scholar
- Baral, S., Beyrer, C., Muessig, K., Poteat, T., Wirtz, A. L., Decker, M. R., & Kerrigan, D. (2012). Burden of HIV among female sex workers in low-income and middle-income countries: A systematic review and meta-analysis. The Lancet Infectious Diseases,12(7), 538–549. https://doi.org/10.1016/S1473-3099(12)70066-X.CrossRefPubMedGoogle Scholar
- Chen, Y., Shen, Z., Morano, J. P., Khoshnood, K., Wu, Z., Lan, G., & Liu, W. (2015). Bridging the epidemic: A comprehensive analysis of prevalence and correlates of HIV, hepatitis C, and syphilis, and infection among female sex workers in Guangxi province, China. PloS ONE,10(2), e0115311. https://doi.org/10.1371/journal.pone.0115311.CrossRefPubMedPubMedCentralGoogle Scholar
- Decker, M. R., Yam, E. A., Wirtz, A. L., Baral, S. D., Peryshkina, A., Mogilnyi, V., & Beyrer, C. (2013). Induced abortion, contraceptive use, and dual protection among female sex workers in Moscow, Russia. International Journal of Gynecology and Obstetrics,120(1), 27–31. https://doi.org/10.1016/j.ijgo.2012.07.026.CrossRefPubMedGoogle Scholar
- Haeri, S. (1992). Temporary marriage and the state in Iran: An Islamic discourse on female sexuality. Social Research,59(1), 201–223.Google Scholar
- Hoefnagels, C., Hospers, H. J., Hosman, C., Schouten, L., & Schaalma, H. (2006). One measure, two motives. Prediction of condom use and interaction between two prevention goals among heterosexual young adults: Preventing pregnancy and/or sexually transmitted diseases. Prevention Science,7(4), 369–376. https://doi.org/10.1007/s11121-006-0048-z.CrossRefPubMedGoogle Scholar
- Jahani, M. R., Alavian, S. M., Shirzad, H., Kabir, A., & Hajarizadeh, B. (2005). Distribution and risk factors of hepatitis B, hepatitis C, and HIV infection in a female population with “illegal social behaviour”. Sexually Transmitted Infections,81(2), 185. https://doi.org/10.1136/sti.2004.011114.CrossRefPubMedPubMedCentralGoogle Scholar
- Karamouzian, M., Haghdoost, A. A., & Sharifi, H. (2014a). Addressing the needs of sexual partners of people who inject drugs through peer prevention programs in Iran. International Journal of Health Policy and Management,2(2), 81–83. https://doi.org/10.15171/ijhpm.2014.19.CrossRefPubMedPubMedCentralGoogle Scholar
- Karamouzian, M., Madani, N., Doroudi, F., & Haghdoost, A. A. (2017a). Improving the quality and quantity of HIV data in the Middle East and North Africa: Key challenges and ways forward. International Journal of Health Policy and Management,6(2), 65–69. https://doi.org/10.15171/ijhpm.2016.112.CrossRefPubMedGoogle Scholar
- Karamouzian, M., Madani, N., Doroudi, F., & Haghdoost, A. A. (2018). Tackling HIV in MENA: Talk is not enough—It is time for bold actions: A response to recent commentaries. International Journal of Health Policy and Management,7(2), 199–200. https://doi.org/10.15171/ijhpm.2017.110.CrossRefPubMedGoogle Scholar
- Karamouzian, M., Mirzazadeh, A., Rawat, A., Shokoohi, M., Haghdoost, A. A., Sedaghat, A., & Sharifi, H. (2017b). Injection drug use among female sex workers in Iran: Findings from a nationwide bio-behavioural survey. International Journal of Drug Policy,44, 86–91. https://doi.org/10.1016/j.drugpo.2017.03.011.CrossRefPubMedGoogle Scholar
- Karamouzian, M., Mirzazadeh, A., Shokoohi, M., Khajehkazemi, R., Sedaghat, A., Haghdoost, A. A., & Sharifi, H. (2016b). Lifetime abortion of female sex workers in Iran: Findings of a national bio-behavioural survey in 2010. PLoS ONE,11(11), e0166042. https://doi.org/10.1371/journal.pone.0166042.CrossRefPubMedPubMedCentralGoogle Scholar
- Kayembe, P. K., Mapatano, M. A., Busangu, A. F., Nyandwe, J. K., Mashinda, D. K., Musema, G. M., & Mayala, G. M. (2008). Determinants of consistent condom use among female commercial sex workers in the Democratic Republic of Congo: Implications for interventions. Sexually Transmitted Infections,84(3), 202–206. https://doi.org/10.1136/sti.2007.028324.CrossRefPubMedGoogle Scholar
- Kazerooni, P. A., Motazedian, N., Motamedifar, M., Sayadi, M., Sabet, M., Lari, M. A., & Kamali, K. (2014). The prevalence of human immunodeficiency virus and sexually transmitted infections among female sex workers in Shiraz, South of Iran: By respondent-driven sampling. International Journal of STD and AIDS,25(2), 155–161. https://doi.org/10.1177/0956462413496227.CrossRefPubMedGoogle Scholar
- Larney, S., Mathers, B. M., Poteat, T., Kamarulzaman, A., & Degenhardt, L. (2015). Global epidemiology of HIV among women and girls who use or inject drugs: Current knowledge and limitations of existing data. Journal of Acquired Immune Deficiency Syndromes,69(Suppl. 2), S100. https://doi.org/10.1097/QAI.0000000000000623.CrossRefPubMedGoogle Scholar
- Mahapatra, B., Lowndes, C. M., Mohanty, S. K., Gurav, K., Ramesh, B. M., Moses, S., & Alary, M. (2013). Factors associated with risky sexual practices among female sex workers in Karnataka, India. PloS ONE,8(4), e62167. https://doi.org/10.1371/journal.pone.0062167.CrossRefPubMedPubMedCentralGoogle Scholar
- Malta, M., Magnanini, M. M., Mello, M. B., Pascom, A. R. P., Linhares, Y., & Bastos, F. I. (2010). HIV prevalence among female sex workers, drug users and men who have sex with men in Brazil: A systematic review and meta-analysis. BMC Public Health,10(1), 317. https://doi.org/10.1186/1471-2458-10-317.CrossRefPubMedPubMedCentralGoogle Scholar
- Ministry of Health and Medical Education. (2015). Islamic Republic of Iran AIDS Progress Report. Retrieved January 15, 2019, from www.unaids.org/sites/default/files/country/documents/IRN_narrative_report_2015.pdf.
- Mirzazadeh, A., Shokoohi, M., Khajehkazemi, R., Hosseini Hooshyar, S., Karamouzian, M., Nadji, S., … Haghdoost, A. A. (2016). HIV and Sexually Transmitted Infections Among Female Sex Workers in Iran: Findings From the 2010 and 2015 National Surveillance Surveys. Retrieved January 15, 2019, from www.programme.aids2016.org/Abstract/Index.
- Moayedi-Nia, S., Bayat Jozani, Z., Esmaeeli Djavid, G., Entekhabi, F., Bayanolhagh, S., Saatian, M., & Mohraz, M. (2016). HIV, HCV, HBV, HSV, and syphilis prevalence among female sex workers in Tehran, Iran, by using respondent-driven sampling. AIDS Care,28(4), 487–490. https://doi.org/10.1080/09540121.2015.1109582.CrossRefPubMedGoogle Scholar
- Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Annals of Internal Medicine,151(4), 264–269. https://doi.org/10.7326/0003-4819-151-4-200908180-00135.CrossRefGoogle Scholar
- Munn, Z., Moola, S., Lisy, K., Riitano, D., & Tufanaru, C. (2015). Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. International Journal of Evidence-based Healthcare,13(3), 147–153. https://doi.org/10.1097/XEB.0000000000000054.CrossRefPubMedGoogle Scholar
- Nasirian, M., Kianersi, S., Hoseini, S. G., Kassaian, N., Yaran, M., Shoaei, P., & Jalilian, M. R. (2017). Prevalence of sexually transmitted infections and their risk factors among female sex workers in Isfahan, Iran: A cross-sectional study. Journal of the International Association of Providers of AIDS Care,16(6), 608–614. https://doi.org/10.1177/2325957417732836.CrossRefPubMedGoogle Scholar
- Rehm, J., Probst, C., Shield, K. D., & Shuper, P. A. (2017). Does alcohol use have a causal effect on HIV incidence and disease progression? A review of the literature and a modeling strategy for quantifying the effect. Population Health Metrics,15(1), 4. https://doi.org/10.1186/s12963-017-0121-9.CrossRefPubMedPubMedCentralGoogle Scholar
- Sajadi, L., Mirzazadeh, A., Navadeh, S., Osooli, M., Khajehkazemi, R., Gouya, M. M., … Haghdoost, A. A. (2013). HIV prevalence and related risk behaviours among female sex workers in Iran: Results of the national biobehavioural survey 2010. Sexually Transmitted Infections,89(Suppl. 3), iii37–iii40. https://doi.org/10.1136/sextrans-2013-051028.CrossRefPubMedPubMedCentralGoogle Scholar
- Shahesmaeili, A., Karamouzian, M., Shokoohi, M., Kamali, K., Fahimfar, N., Nadji, A., & Mirzazadeh, A. (2018). Symptom-based versus laboratory-based diagnosis of five sexually transmitted infections in female sex workers in Iran. AIDS and Behavior,22(Suppl. 1), 19–25. https://doi.org/10.1007/s10461-018-2130-5.CrossRefPubMedPubMedCentralGoogle Scholar
- Sharifi, H., Karamouzian, M., Baneshi, M. R., Shokoohi, M., Haghdoost, A., McFarland, W., & Mirzazadeh, A. (2017). Population size estimation of female sex workers in Iran: Synthesis of methods and results. PloS ONE,12(8), e0182755. https://doi.org/10.1371/journal.pone.0182755.CrossRefPubMedPubMedCentralGoogle Scholar
- Taghizadeh, H., Taghizadeh, F., Fathi, M., Reihani, P., Shirdel, N., & Rezaee, S. M. (2015). Drug use and high-risk sexual behaviors of women at a drop-in center in Mazandaran province, Iran, 2014. Iranian Journal of Psychiatry and Behavioral Sciences,9(2), e1047. https://doi.org/10.17795/ijpbs1047.CrossRefPubMedPubMedCentralGoogle Scholar
- Todd, C. S., Alibayeva, G., Khakimov, M. M., Sanchez, J. L., Bautista, C. T., & Earhart, K. C. (2007). Prevalence and correlates of condom use and HIV testing among female sex workers in Tashkent, Uzbekistan: Implications for HIV transmission. AIDS and Behavior,11(3), 435–442. https://doi.org/10.1007/s10461-006-9155-x.CrossRefPubMedGoogle Scholar
- UNAIDS. (2018). Country Factsheet: Islamic Republic of Iran. Retrieved January 15, 2019, from www.unaids.org/en/regionscountries/countries/islamicrepublicofiran.
- Vafaei, H., Asadi, N., Foroughinia, L., Salehi, A., Kuhnavard, S., Akbarzadeh, M., & Kasraeian, M. (2015). Comparison of abnormal cervical cytology from HIV positive women, female sex workers and general population. International Journal of Community Based Nursing and Midwifery,3(2), 76–83.PubMedPubMedCentralGoogle Scholar
- Wang, C., Hawes, S. E., Gaye, A., Sow, P. S., Ndoye, I., Manhart, L. E., & Kiviat, N. B. (2007). HIV prevalence, previous HIV testing, and condom use with clients and regular partners among Senegalese commercial sex workers. Sexually Transmitted Infections,83(7), 534–540. https://doi.org/10.1136/sti.2007.027151.CrossRefPubMedPubMedCentralGoogle Scholar