---
title: "Violence and HIV outcomes in female sex workers: global systematic review and meta-analysis"
id: "plos-medicine-3-impact-of-violence-on-hiv-outcomes-among-female-sex-workers-a-global-systematic"
canonical_url: "https://medichelpline.com/clinical-feed/plos-medicine-3-impact-of-violence-on-hiv-outcomes-among-female-sex-workers-a-global-systematic"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "PLOS Medicine"
source_url: "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977"
published_at: "2026-10-21T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Violence and HIV outcomes in female sex workers: global systematic review and meta-analysis
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-medicine-3-impact-of-violence-on-hiv-outcomes-among-female-sex-workers-a-global-systematic
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** PLOS Medicine
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977)
- **Published At:** 2026-10-21T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- The authors conducted a global systematic review and meta-analysis of studies from 2010–2026 examining associations between experiences of **violence** and HIV outcomes among **female sex workers** (FSWs). - The search covered MEDLINE, Embase, and PsycINFO with no language or design restriction; included studies could report multiple estimates for different outcomes or exposures. - Ninety-four studies were included, yielding 226 estimates and representing 186,613 FSWs across 39 countries; about half of studies were in low- and middle-income countries and one-fifth in low-income countries. - Investigators pooled adjusted estimates preferentially, using multi-level random-effects meta-analyses to compare recent (past year) and lifetime exposure to physical, sexual, emotional/psychological, and financial violence with HIV endpoints. - Data indicated higher odds of prevalent **HIV** infection among FSWs reporting recent violence (pooled OR 1.31) and lifetime violence (pooled OR 1.35); heterogeneity varied across pooled estimates. - When disaggregated by violence type, sexual violence produced the largest pooled associations with prevalent HIV for both recent (pOR 1.55) and lifetime (pOR 1.40) exposures. - Recent exposure to violence was associated with reduced odds of **ART use** (pOR 0.78); lifetime exposure was associated with reduced odds of viral suppression (pOR 0.88). - No pooled association was found between violence and HIV incidence, HIV testing uptake, or ART adherence in the included studies. - Major limitations the study team noted included predominance of cross-sectional designs, heterogeneity among studies, and challenges in measuring experiences of violence robustly. - The authors concluded that interventions for FSWs should integrate violence prevention and response as part of HIV programming, given the observed links to worse HIV outcomes.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosmedicine%2Farticle%3Fid%3D10.1371%2Fjournal.pmed.1004977) * * About * Browse * Publish * [](https://journals.plos.org/plosmedicine/ "PLOS Medicine") * Search [advanced search](https://journals.plos.org/plosmedicine/search) * 0 [Save](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#savedHeader) * 0 [Citation](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#citedHeader) * 45 [View](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#viewedHeader) * 0 [Share](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977#discussedHeader) Open Access Peer-reviewed Research Article # Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis * Joshua Dawe , Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Software, Visualization, Writing – original draft, Writing – review & editing * E-mail: joshua.dawe@bristol.ac.uk (JD); j.stone@bristol.ac.uk (JS) Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-3227-9849 ](https://orcid.org/0000-0002-3227-9849 "ORCID Registry") ⨯ * Khadimul Anam Mazhar, Roles Conceptualization, Funding acquisition, Methodology Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-9303-6541 ](https://orcid.org/0000-0002-9303-6541 "ORCID Registry") ⨯ * Saher Aijaz Khan, Roles Conceptualization, Funding acquisition, Methodology Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-1316-359X ](https://orcid.org/0000-0003-1316-359X "ORCID Registry") ⨯ * Belinda Jackson Njiro, Roles Data curation, Investigation, Writing – review & editing Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-8312-0643 ](https://orcid.org/0000-0002-8312-0643 "ORCID Registry") ⨯ * Victoria Bendaud, Roles Conceptualization, Funding acquisition, Project administration Affiliation Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland ⨯ * Keith Sabin, Roles Conceptualization, Funding acquisition, Project administration, Writing – review & editing Affiliation Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-2290-8621 ](https://orcid.org/0000-0002-2290-8621 "ORCID Registry") ⨯ * Julie Ambia, Roles Investigation Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England ⨯ * Adam Trickey, Roles Investigation, Writing – review & editing Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-3462-2898 ](https://orcid.org/0000-0003-3462-2898 "ORCID Registry") ⨯ * Lucy Barrass, Roles Investigation, Writing – review & editing Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0001-6557-1523 ](https://orcid.org/0000-0001-6557-1523 "ORCID Registry") ⨯ * Asra Asgharzadeh, Roles Investigation Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England ⨯ * Jack Stone , Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing * E-mail: joshua.dawe@bristol.ac.uk (JD); j.stone@bristol.ac.uk (JS) Affiliation Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-4584-0068 ](https://orcid.org/0000-0002-4584-0068 "ORCID Registry") ⨯ * Adelina Artenie , Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing ¶‡ These authors are joint senior authors on this work. Affiliations Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England, Department of Family and Emergency Medicine, Faculty of Medicine, University of Montreal, Montreal, Canada, Centre de recherche du Centre hospitalier de l’Université de Montréal, University of Montreal, Montreal, Canada [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-3085-2410 ](https://orcid.org/0000-0002-3085-2410 "ORCID Registry") ⨯ * Peter Vickerman Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing ¶‡ These authors are joint senior authors on this work. Affiliations Bristol Population Health Science Institute, Bristol Medical School, University of Bristol, Bristol, England, Health Protection Research Unit, Bristol Medical School, University of Bristol, Bristol, England [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-8291-5890 ](https://orcid.org/0000-0002-8291-5890 "ORCID Registry") ⨯ # Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis * Joshua Dawe, * Khadimul Anam Mazhar, * Saher Aijaz Khan, * Belinda Jackson Njiro, * Victoria Bendaud, * Keith Sabin, * Julie Ambia, … * Adam Trickey, * Lucy Barrass, * Asra Asgharzadeh ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: October 21, 2026 * * [Article](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977) * [Authors](https://journals.plos.org/plosmedicine/article/authors?id=10.1371/journal.pmed.1004977) * [Metrics](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004977) * [Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1004977) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pmed.1004977) * [Peer Review](https://journals.plos.org/plosmedicine/article/peerReview?id=10.1371/journal.pmed.1004977) * [Abstract](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#abstract0) * [Author summary](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#abstract1) * [Introduction](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#sec007) * [Methods](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#sec008) * [Results](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#sec013) * [Discussion](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#sec023) * [Supporting information](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#sec024) * [References](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#references) * [Reader Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1004977) * [Figures](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977) ![Accessible Data Icon](https://journals.plos.org/resource/img/accessible_data.svg)Accessible Data [ See the data ![Link Icon](https://journals.plos.org/resource/img/data_link_icon.svg) ](https://doi.org/10.5281/zenodo.22809473) This article includes the Accessible Data icon, an experimental feature to encourage data sharing and reuse. [Find out how research articles qualify for this feature.](https://theplosblog.plos.org/2023/07/accessible-data/) [?](https://journals.plos.org/plosmedicine/s/accepted-manuscripts#loc-early-version) ## This is an uncorrected proof. ## Abstract ### 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. ## Author summary ### Why was this study done? * Female sex workers (FSW) have higher HIV acquisition risk and poorer HIV treatment outcomes compared with women in the general population. * Structural factors, such as criminalisation of sex work, stigma, discrimination, and violence, are increasingly recognised as drivers of HIV risk. * However, no systematic review has yet quantitatively synthesised evidence on the associations between experiences of different forms of violence and HIV outcomes, including HIV infection, HIV testing uptake, ART use, ART adherence, and HIV viral suppression. ### What did the researchers do and find? * To our knowledge, we conducted the first global systematic review and meta-analysis quantifying the associations between physical, sexual, and other forms of violence with HIV outcomes among FSWs. * Our review included 94 studies from 39 countries, comprising 186,613 FSWs. * In pooled analyses, both recent and lifetime exposure to all forms of violence had strong associations with increased odds of prevalent HIV infections. * Experiences of violence were also associated with poorer HIV treatment outcomes, including reduced ART use among FSWs with recent experiences of violence, and reduced levels of viral suppression among FSWs with lifetime experiences of violence. ### What do these findings mean? * Our findings provide the most comprehensive evidence to date of the detrimental impact of violence on HIV outcomes among FSWs. * Our results underscore the need to integrate violence prevention interventions and responses into HIV programmes tailored for FSWs, including structural interventions to address the legal, social, and economic contexts that enable violence. * The main limitations of our study were the heterogeneity in pooled effects and that most of the included studies were cross-sectional. ## Figures ![Fig 3](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g003) ![Fig 4](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g004) ![Fig 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g001) ![Table 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.t001) ![Fig 2](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g002) ![Fig 3](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g003) ![Fig 4](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g004) ![Fig 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g001) ![Table 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.t001) ![Fig 2](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004977.g002) **Citation:** Dawe J, Mazhar KA, Khan SA, Njiro BJ, Bendaud V, Sabin K, et al. (2026) Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis. PLoS Med 23(10): e1004977. https://doi.org/10.1371/journal.pmed.1004977 **Academic Editor:** Alexander C. Tsai, Massachusetts General Hospital, UNITED STATES OF AMERICA **Received:** February 18, 2026; **Accepted:** September 18, 2026; **Published:** October 21, 2026 **Copyright:** © 2026 Dawe et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** The finalised data extraction and analysis code is publicly available at . **Funding:** JD and SAK received funding from the GW4 BioMed MRC Doctoral Training Partnership ( ). KAM and JA received funding from a University of Bristol Postgraduate Research Scholarship ( ). JD, KAM, SAK, JS, AA, and PV received funding from the Joint United Nations Programme on HIV/AIDS (UNAIDS) ( ) (grant code 2024/1464836). AT, JS, AA, and PV received funding from the Wellcome Trust ( ) (grant code 226619/Z/22/Z). KS and VB are employed by the funders (UNAIDS) and supported the funding acquisition, project administration, the conceptualisation of the project, and reviewed the final draft before submission. **Competing interests:** The authors have declared that no competing interests exist. **Abbreviations:** FSWs, female sex workers; LMICs, low- and middle-income countries; OR, odds ratio; pOR, pooled odds ratio; PR, prevalence ratio; PRISMA, preferred reporting items for systematic reviews and meta-analyses; RR, risk ratio. ## Introduction Despite ongoing global efforts, the HIV epidemic continues to have considerable global health impacts, particularly in low- and middle-income countries (LMICs) [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref001)]. Whilst HIV incidence has declined in many countries, new infections are increasingly concentrated among key populations, such as female sex workers (FSWs) [[2](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref002)]. In 2022, a global modelling analysis estimated that FSWs had nine times higher risk of acquiring HIV than the adult male and female population, and 18% of incident HIV infections globally occurred among FSWs and their clients [[3](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref003),[4](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref004)]. Furthermore, evidence suggests that in many settings inequities exist in the HIV cascade of care among FSWs, including suboptimal antiretroviral therapy (ART) coverage and HIV viral suppression [[5](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref005)–[7](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref007)]. The reasons for heightened levels of infection and poorer treatment outcomes among FSWs compared to the general population are multifaceted, and result from complex interplays between societal, behavioural, and other distal factors [[8](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref008)]. These include structural factors outside individual control, which influence the risk environment in which FSWs live and work, including the criminalisation of sex work, stigma and discrimination, and violence [[9](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref009)]. Studies have described how violence can contribute directly to HIV transmission, as well as influence HIV risk behaviours such as condomless sex and substance use [[10](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref010)–[12](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004977#pmed.1004977.ref012)]. Modelling has also shown the potential impact of violence reduction interventions on averting HIV infections [[13](https://journals.plos.org/plosmedicine
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