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

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.