Post on 20-Apr-2023
Behavioral interventions to reduce the transmission of HIV
infection among sex workers and their clients in low- and
middle-income countries (Review)
Wariki WMV, Ota E, Mori R, Koyanagi A, Hori N, Shibuya K
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2012, Issue 2
http://www.thecochranelibrary.com
Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
6BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
17ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .
27DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
56DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 1
HIV incidence among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis 1.2. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 2
STIs incidence among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis 1.3. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 3
Consistent condom use by FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . 65
Analysis 1.4. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 4
Mean number of condom use by FSWs at past month. . . . . . . . . . . . . . . . . . . . . 66
Analysis 1.5. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 5
Mean number of protected sex among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . 67
Analysis 1.6. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 6
Sexual activity outcomes by FSWs at past month. . . . . . . . . . . . . . . . . . . . . . 67
Analysis 1.7. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 7
Injected drug use among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . 68
Analysis 1.8. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 8
Alcohol use among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . 68
Analysis 1.9. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom use, Outcome 9
Drug use among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Analysis 2.1. Comparison 2 Social cognitive theory versus no intervention for promotion of condom use, Outcome 1
Consistent condom use by FSWs. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Analysis 2.2. Comparison 2 Social cognitive theory versus no intervention for promotion of condom use, Outcome 2 HIV
knowledge among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . 70
Analysis 2.3. Comparison 2 Social cognitive theory versus no intervention for promotion of condom use, Outcome 3
Psychosocial barriers to condom use among FSWs at 6-month. . . . . . . . . . . . . . . . . . 70
Analysis 3.1. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 1
STIs prevalence among FSWs at 36-month. . . . . . . . . . . . . . . . . . . . . . . . 71
Analysis 3.2. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 2
Consistent condom use by FSWs with regular partners. . . . . . . . . . . . . . . . . . . . 71
Analysis 3.3. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 3
Consistent condom use by FSWs with clients. . . . . . . . . . . . . . . . . . . . . . . . 72
Analysis 3.4. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 4
Change in 100% condom use by FSWs. . . . . . . . . . . . . . . . . . . . . . . . . . 72
iBehavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.5. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 5
Change in any condom use by FSWs. . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 3.6. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 6
HIV knowledge among FSWs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 3.7. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 7
HIV testing by FSWs at 36-month. . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Analysis 3.8. Comparison 3 Community empowerment versus standard care for promotion of condom use, Outcome 8
Skills of risk and protective factors among FSWs at 16-month. . . . . . . . . . . . . . . . . . 74
Analysis 4.1. Comparison 4 Microenterprise plus education intervention versus education alone for reducing the number
of sex partners, Outcome 1 Consistent condom use by FSWs at 6-month. . . . . . . . . . . . . . 75
Analysis 4.2. Comparison 4 Microenterprise plus education intervention versus education alone for reducing the number
of sex partners, Outcome 2 Number of FSWs’ partners at 6-month. . . . . . . . . . . . . . . . 75
Analysis 5.1. Comparison 5 Peer education versus standard care for promoting HIV testing and condom use, Outcome 1
Mean number of consistent condom use by FSWs at 6-month. . . . . . . . . . . . . . . . . . 76
Analysis 5.2. Comparison 5 Peer education versus standard care for promoting HIV testing and condom use, Outcome 2
Mean score of HIV knowledge among FSWs at 6-month. . . . . . . . . . . . . . . . . . . 76
Analysis 5.3. Comparison 5 Peer education versus standard care for promoting HIV testing and condom use, Outcome 3
HIV testing by FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis 5.4. Comparison 5 Peer education versus standard care for promoting HIV testing and condom use, Outcome 4
AIDS perceived control by FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis 5.5. Comparison 5 Peer education versus standard care for promoting HIV testing and condom use, Outcome 5
AIDS perceived severity by FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . 78
Analysis 6.1. Comparison 6 Peer education plus clinic based counseling versus peer education only for promotion of
condom use, Outcome 1 STIs prevalence among FSWs. . . . . . . . . . . . . . . . . . . . 78
Analysis 6.2. Comparison 6 Peer education plus clinic based counseling versus peer education only for promotion of
condom use, Outcome 2 Male condom use with clients. . . . . . . . . . . . . . . . . . . . 79
Analysis 6.3. Comparison 6 Peer education plus clinic based counseling versus peer education only for promotion of
condom use, Outcome 3 Male condom use with non-paying partners. . . . . . . . . . . . . . . 80
Analysis 6.4. Comparison 6 Peer education plus clinic based counseling versus peer education only for promotion of
condom use, Outcome 4 Female condom use by FSWs with clients. . . . . . . . . . . . . . . . 80
Analysis 6.5. Comparison 6 Peer education plus clinic based counseling versus peer education only for promotion of
condom use, Outcome 5 Male and female condom use with clients. . . . . . . . . . . . . . . . 81
Analysis 6.6. Comparison 6 Peer education plus clinic based counseling versus peer education only for promotion of
condom use, Outcome 6 Male and female condom use in the last sex with non-paying partner. . . . . . . 81
Analysis 7.1. Comparison 7 Peer education plus manager training versus standard care for promoting HIV testing and
condom use, Outcome 1 Mean number of consistent condom use by FSWs at 6-month. . . . . . . . . 82
Analysis 7.2. Comparison 7 Peer education plus manager training versus standard care for promoting HIV testing and
condom use, Outcome 2 Mean score of HIV knowledge among FSWs at 6-month. . . . . . . . . . . 82
Analysis 7.3. Comparison 7 Peer education plus manager training versus standard care for promoting HIV testing and
condom use, Outcome 3 HIV testing by FSWs at 6-month. . . . . . . . . . . . . . . . . . . 83
Analysis 7.4. Comparison 7 Peer education plus manager training versus standard care for promoting HIV testing and
condom use, Outcome 4 AIDS perceived control by FSWs at 6-month. . . . . . . . . . . . . . . 83
Analysis 7.5. Comparison 7 Peer education plus manager training versus standard care for promoting HIV testing and
condom use, Outcome 5 AIDS perceived severity by FSWs at 6-month. . . . . . . . . . . . . . . 84
Analysis 8.1. Comparison 8 Manager training versus standard care for promoting HIV testing and condom use, Outcome
1 Mean number of consistent condom use by FSWs at 6-month. . . . . . . . . . . . . . . . . 84
Analysis 8.2. Comparison 8 Manager training versus standard care for promoting HIV testing and condom use, Outcome
2 Mean score of HIV knowledge among FSWs at 6-month. . . . . . . . . . . . . . . . . . . 85
Analysis 8.3. Comparison 8 Manager training versus standard care for promoting HIV testing and condom use, Outcome
3 HIV testing by FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Analysis 8.4. Comparison 8 Manager training versus standard care for promoting HIV testing and condom use, Outcome
4 AIDS perceived control by FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . 86
iiBehavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 8.5. Comparison 8 Manager training versus standard care for promoting HIV testing and condom use, Outcome
5 Mean score of perceived themselves at greater risk (by FSWs at 6-month). . . . . . . . . . . . . 86
Analysis 9.1. Comparison 9 Promotion of female and male condom versus promotion of male condom, Outcome 1 HIV
incidence among FSWs at 3-month. . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis 9.2. Comparison 9 Promotion of female and male condom versus promotion of male condom, Outcome 2 STIs
incidence among FSWs at 3-month. . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis 9.3. Comparison 9 Promotion of female and male condom versus promotion of male condom, Outcome 3
Consistent male condom use at 3-months. . . . . . . . . . . . . . . . . . . . . . . . . 88
Analysis 9.4. Comparison 9 Promotion of female and male condom versus promotion of male condom, Outcome 4
Consistent female condom use by FSWs at 3-month. . . . . . . . . . . . . . . . . . . . . 88
Analysis 9.5. Comparison 9 Promotion of female and male condom versus promotion of male condom, Outcome 5
Consistent female condom use by FSWs at 24-month. . . . . . . . . . . . . . . . . . . . . 89
Analysis 9.6. Comparison 9 Promotion of female and male condom versus promotion of male condom, Outcome 6
Consistent male condom use at 24-month. . . . . . . . . . . . . . . . . . . . . . . . . 89
Analysis 10.1. Comparison 10 Intensive STI screening versus basic STI screening to control STI, Outcome 1 HIV incidence
among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Analysis 10.2. Comparison 10 Intensive STI screening versus basic STI screening to control STI, Outcome 2 STIs
prevalence among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Analysis 10.3. Comparison 10 Intensive STI screening versus basic STI screening to control STI, Outcome 3 Consistent
condom use by FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 11.1. Comparison 11 VCT versus standard care of STI for increasing condom use, Outcome 1 STIs prevalence
among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 11.2. Comparison 11 VCT versus standard care of STI for increasing condom use, Outcome 2 Consistent condom
use by FSWs with clients at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . 92
Analysis 11.3. Comparison 11 VCT versus standard care of STI for increasing condom use, Outcome 3 HIV/STI
knowledge among FSWs at 6-month. . . . . . . . . . . . . . . . . . . . . . . . . . 92
92APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
95HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
95CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
96DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
96SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
96DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
96INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiiBehavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Behavioral interventions to reduce the transmission of HIVinfection among sex workers and their clients in low- andmiddle-income countries
Windy MV Wariki1, Erika Ota1, Rintaro Mori2, Ai Koyanagi1 , Narumi Hori3, Kenji Shibuya1
1Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. 2Collaboration for
Research in Global Women’s and Children’s Health, Tokyo, Japan. 3Faculty of Nursing, St. Luke’s College of Nursing, Tokyo, Japan
Contact address: Windy MV Wariki, Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, 7-
3-1 Hongo Bunkyo-ku, Tokyo, 113-0033, Japan. wwariki@yahoo.com.
Editorial group: Cochrane HIV/AIDS Group.
Publication status and date: New, published in Issue 2, 2012.
Review content assessed as up-to-date: 15 March 2011.
Citation: Wariki WMV, Ota E, Mori R, Koyanagi A, Hori N, Shibuya K. Behavioral interventions to reduce the transmission of HIV
infection among sex workers and their clients in low- and middle-income countries. Cochrane Database of Systematic Reviews 2012,
Issue 2. Art. No.: CD005272. DOI: 10.1002/14651858.CD005272.pub3.
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Various interventions have been adopted to reduce HIV transmission among sex workers and their clients but the effectiveness of these
strategies has yet to be investigated using meta-analytic techniques.
Objectives
To evaluate the effectiveness of behavioral interventions to reduce the transmission of HIV infection among sex workers and their
clients in low- and middle-income countries.
Search methods
The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane HIV/AIDS group specialized register, the Cochrane
Database of Systematic Reviews, MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, Dissertation Abstract International (DAI),
EMBASE, LILACS, BIOSIS, SciSearch, INDMED, Proquest, and various South Asian abstracting databases were included in the
database list. The publication sites of the World Health Organization, the US Centers for Disease Control and Prevention, and other
international research and non-governmental organizations also appeared in the database list.
Selection criteria
Randomized controlled trials (RCTs) and quasi-RCTs examining the effects on HIV transmission risk of different behavioral inter-
ventions or comparing behavioral interventions with no intervention, where described any one of the outcome measures, such as HIV
incidence and prevalence, STI incidence and prevalence, change in self-reported of condom use, and other HIV-related outcome.
Data collection and analysis
Two authors independently assessed trials, extracted data and assessed the risk bias. Heterogeneity amongst trials was also tested.
1Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
A total of 13 trials with 8,698 participants were included. Primary outcomes (HIV and STI prevalence and incidence) were reported
in seven trials. Of these, HIV incidence was reported in only three trials. After a 6-month follow-up assessment, there was no evidence
that social cognitive behavioral intervention was effective in reducing HIV incidence (RR 0.12, 95% CI 0.01 to 2.22). However, there
was a reduction in HIV incidence at 3-month follow-up assessment of promotion of female and male condom (RR 0.07, 95% CI 0.00
to 1.38). Social cognitive interventions and promotion of female and male condom use were significantly reduced STIs incidence (RR
0.57, 95% CI 0.34 to 0.96) and (RR 0.63, 95% CI 0.45 to 0.88), respectively. Secondary outcomes were identified in 13 trials. Meta-
analyses showed evidence that interventions to promote the use of female and male condoms do reduce non-condom use (RR 0.83,
95% CI 0.65 to 1.05) compared to promotion of male condoms alone, and that social cognitive interventions reduced drug use among
sex workers (RR 0.65, 95% CI 0.36 to 1.16) compared to standard care.
Authors’ conclusions
Available evidence nevertheless suggests that compared with standard care or no intervention, behavioral interventions are effective in
reducing HIV and the incidence of STIs amongst female sex workers (FSWs). Given the benefits of social cognitive theory and the
promotion of condom use in reducing HIV/STI and the public health need to control transmission amongst FSWs, there is a clear
finding in favour of behavioral interventions. However, it should be recognized that there is a lack of information about most other
outcomes and target populations, and that all of the trials were conducted in low- and middle-income countries.
P L A I N L A N G U A G E S U M M A R Y
Behavioral interventions to reduce HIV incidence and HIV/STI prevalence among female sex workers in low- and middle-
income countries
The rates of human immunodeficiency virus (HIV) and sexually transmitted infection (STI) transmission continue to increase, partic-
ularly among sex workers and their clients in low- and middle-income countries. Prevention efforts directed towards these infections
in this at-risk population may have had an effect in reducing the overall transmission of HIV/STIs in the general population. Several
successful behavioral interventions have been reported including interventions to reduce HIV/STI incidence and prevalence, change
behavior, promote condom use, improve condom availability, and increase sexual health knowledge. The review found seven individual
randomised controlled trials (RCTs), two cluster-RCTs and four quasi-RCTs involving 8,698 participants examining a variety of be-
havioral interventions to evaluate whether they reduced HIV/STIs rates or resulted in changed behavior among sex workers and their
clients. Results showed that the interventions were effective in HIV/STI prevention, including reducing the incidence and prevalence
of HIV and STIs. Furthermore, there were some differences in self-reported behavior including increased condom use and a reduction
in the risk of drug use. However, these trials were small and generally had few participants. As a result, evidence for the effectiveness
of social cognitive theory and promoting condom use in reducing HIV/STI incidence compared to other behavioral interventions was
limited, because no RCTs examined the effects of these interventions on HIV prevalence or on sex workers other than FSWs. In future
research and program agendas therefore it is important to assess other potentially more potent behavioral change strategies.
2Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
SU
MM
AR
YO
FF
IN
DI
NG
SF
OR
TH
EM
AI
NC
OM
PA
RI
SO
N[E
xpla
nati
on]
Socialcognitivetheorycomparedtostandardcounselingforpromotionofcondomuseforsexworkers
Patientorpopulation:sexworkers
Settings:low-andmiddle-incomecountries
Intervention:Socialcognitivetheory
Comparison:standardcounselingforprom
otionofcondom
use
Outcomes
Illustrative
comparativerisks*
(95%CI)
Relativeeffect
(95%CI)
NoofParticipants
(studies)
Qualityoftheevidence
(GRADE)
Com
ments
Assumed
risk
Correspondingrisk
standard
counselingfor
promotion
ofcondom
use
Socialcognitivetheory
HIV
incidence
among
FSWsat6-month
Studypopulation
RR0.12
(0.01to2.22)
709
(1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
11per1000
1per1000
(0to24)
Mediumriskpopulation
11per1000
1per1000
(0to24)
Syphilis
incidence
amongFSWsat6-month
Studypopulation
RR0.46
(0.18to1.19)
709
(1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
38per1000
17per1000
(7to45)
Mediumriskpopulation
38per1000
17per1000
(7to45)
3Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gonorrhoea
incidence
amongFSWsat6-month
Studypopulation
RR0.69
(0.3to1.58)
709
(1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
38per1000
26per1000
(11to60)
Mediumriskpopulation
38per1000
26per1000
(11to60)
Any
STIs
incidence
amongFSWsat6-month
Studypopulation
RR0.57
(0.34to0.96)
709
(1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
103per1000
59per1000
(35to99)
Mediumriskpopulation
103per1000
59per1000
(35to99)
Consistentcondom
use
byFSWsat6-month
Studypopulation
RR1.14
(1.07to1.21)
804
(2studies)
⊕©
©©
verylow
6,7,8,9,10
767per1000
867per1000
(805
to920)
Mediumriskpopulation
789per1000
892per1000
(828
to947)
Druguse
amongFSWs
at6-month
Studypopulation
RR0.65
(0.36to1.16)
772
(2studies)
⊕⊕
©©
low
3,6,7,10,11
141per1000
93per1000
(65to134)
Mediumriskpopulation
4Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
236per1000
156per1000
(109
to224)
Alcohol
use
among
FSWsat6-month
Studypopulation
RR0.68
(0.46to1.00)
772
(2studies)
⊕⊕
©©
low
3,6,7,10,11
144per1000
98per1000
(66to144)
Mediumriskpopulation
128per1000
87per1000
(59to128)
*The
basisfortheassumedrisk
(e.g.themediancontrolgroupriskacross
studies)isprovided
infootnotes.Thecorrespondingrisk(and
its95%confidence
interval)isbasedon
the
assumedriskinthecomparison
groupandtherelativeeffectoftheintervention(andits95%CI).
CI:Confidenceinterval;RR:Riskratio;
GRADEWorkingGroupgradesofevidence
Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheestimate.
Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
Verylowquality:Weareveryuncertainabouttheestimate.
1Noseriouslimitations:Allocationconcealmentwasjudgedtobeat‘‘lowriskofbias’’inthistrial.
2Singlestudy.
3Noseriousindirectness:Resultislikelytobereliable.
4Seriousimprecision:The95%CIofestimatecrossesthelineofno
effect.
5Biaswasjudgedtobeat‘‘lowrisk’’inthistrial.
6Seriouslimitations:Allocationconcealmentwasjudged
tobe
at‘‘lowriskofbias’’inPatterson
studyand‘‘unclear’’inWechsberg
study.
7Noseriousinconsistency:Heterogeneitywaslow.
8Serious
indirectness:Thereisconsiderablevariabilityintheeffectofcontrolwhich
makes
extrapolationofresulttoothersetting
unreliable.
9Veryseriousimprecision:The95%CIofpooledestimateincludesappreciablebenefittocontrolgroupoverinterventiongroup.
10Biaswasjudgedtobeat‘‘high
risk’’atW
echsbergtrial.
11Noseriousimprecision:The95%CIofestimateincludesappreciablebenefittointerventiongroupovercontrolgroup.
5Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
B A C K G R O U N D
Description of the condition
In 2008, the Joint United Nations Programme on HIV/AIDS
(UNAIDS) reported that an estimated 2.7 million people (range
2.4-3.0 million) became newly infected with HIV, bringing the
total number of people living with HIV to 33.4 million (range
31.1-35.8 million) worldwide. Overall, 2.0 million (range 1.7-
2.4 million) AIDS-related deaths occurred throughout the world
(UNAIDS 2009). Most newly acquired infections occurred in low-
and middle-income countries, and sub-Saharan Africa remains the
most heavily affected region, mainly as a result of heterosexual
transmission (WHO 2009).
The high rates of HIV infection among sex workers as compared
to most other population groups has affected rates of heterosex-
ual transmission of HIV particularly in low- and middle-income
countries (UNAIDS 2009). The term “sex workers” constitutes a
meaningful single population for epidemiological purposes, but it
encompasses female sex workers, male sex workers, and male-to-
female transgender sex workers in a wide variety of settings (e.g.
brothels, massage parlours, informal settings, and on the street).
Such individuals are often the victims of discrimination (which can
sometimes lead to violence), trafficking, legal persecution and soci-
etal ambivalence (UNAIDS 2002), are socially stigmatised (Padilla
2008) and often have a precarious lifestyle due to economic dif-
ficulties (Gu 2008). Sex workers and their clients, who typically
include people such as truck drivers, security workers, sailors, dock
workers, police, migrant workers and businessmen, are at high risk
for HIV exposure. Moreover, previous research suggests that the
numbers of their clients per night can have an effect on heterosex-
ual transmission of HIV particularly in low- and middle-income
countries (Ruxrungtham 2004). The lifetime probability of a sex
worker becoming infected with HIV is high due to multiple risk
factors, including a large number and high turnover of partners,
low levels of condom use, a high prevalence of STIs, and unsafe
practices such as douching and use of inappropriate lubricants
(UNAIDS 2002).
The number of countries reporting on indicators relating to sex
workers significantly increased between 2005 and 2009. In sub-
Saharan Africa, HIV prevalence among sex workers ranged from
zero in Comoros and Sierra Leone to 49% in Guinea-Bissau. Seven
African countries (Benin, Burundi, Cameroon, Ghana, Guinea-
Bissau, Mali and Nigeria) have reported that more than 30% of all
sex workers had HIV (UNAIDS 2009; Gomes do Espirito Santo
2005). Recently, about one quarter of all sex workers (26%) in
Lesotho were reported to have had a symptomatic STI (Khobotlo
2009). In Swaziland, transmission during heterosexual contact
(including sex within stable couples, casual sex and sex work)
is estimated to account for 94% of incident infections (Mngadi
2009). In 2008, Lowndes et al reported that between 13% and
29% of men in West Africa may have paid for sex in the previous
year (Lowndes 2008). Surveys in Kenya (Gelmon 2009), Uganda
(Wabwire-Mangen 2009) and Rwanda (Asiimwe 2009) suggested
that sex workers and their clients accounted for an estimated 14%,
10% and 46% of incident HIV infections, respectively. Results
from an RCT in Jamaica have shown that 25% of AIDS patients
had had exposure to sex workers (Weir 2008).
Unprotected commercial sex is the most important risk factor for
the spread of HIV in several parts of Asia. In Vietnam, 33% of
male sex workers recruited from more than 70 sites in Ho Chi
Minh City tested positive for HIV (Nguyen 2008). The preva-
lence of HIV among male sex workers is more than twice that of
their female counterparts and is currently rising in Thailand and
Indonesia (UNAIDS 2009). Sex work is common among male-to-
female transgender people in Pakistan (Khan 2008) and high HIV
prevalence has also been reported among transgender sex workers
in studies conducted in Phnom Penh, Cambodia (22%) in 2003
(Girault 2004) and Jakarta, Indonesia (59%) (Pisani 2004). In In-
dia, high HIV and STI prevalence were found among street-based
FSWs (30% and 27%, respectively) and among those who work in
brothels (34% and 13%, respectively) (Buzdugan 2010). Clients
of commercial sex workers are also at high risk of transmission.
Given their high mobility and frequent sexual encounters with sex
workers in other parts of Indonesia, these men could be the agents
of the rapid spread of the HIV virus throughout Indonesia (Fajans
1995).
In the Middle East and North Africa, surveys of bar-based sex
workers in Djibouti have found HIV prevalence as high as 26%,
while in Yemen it has ranged from 1% to 7% (UNAIDS 2009); in
Egypt, 1% (Shawky 2009); while in Algeria, Morocco and Yemen,
the figures are 4%, 2% and 2% of their national populations re-
spectively (UNAIDS 2009). The percentage of sex workers who
report having used a condom during the most recent episode of in-
tercourse ranged from 44% in Jordan to 61% in Yemen (UNAIDS
2009).
Surveys in the Caribbean undertaken in 2005 identified high in-
fection rates in Guyana and Jamaica (27% and 9%, respectively)
(UNAIDS 2009). In Latin America, particularly in Peru, 44% of
men reported having had sex with a sex worker (Caceres 2009).
Surveys in Guatemala and El Salvador have determined HIV
prevalence among FSWs to be 4% and 3%, respectively (Soto
2007).
Description of the intervention
Several successful interventions have been reported among sex
workers and their clients to reduce the heterosexual spread of HIV,
including interventions to change behavior, promote the use of
condoms, improve condom availability, introduce voluntary HIV
counselling and testing (VCT), and educate about sexual health
and the effective management of STIs. The effectiveness of be-
havioral interventions could be increased by aiming for important
goals, such as a delay in the onset of first intercourse, a reduction in
number of sexual partners, an increase in condom use, that could
6Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
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be achieved using multi-level approaches (e.g. targeting couples,
families, social and sexual networks, institutions, and entire com-
munities) with both HIV-uninfected and -infected populations
(Coates 2008).
Female condom interventions may help empower women to pro-
tect themselves when they are unable to avoid sexual relations with
HIV-infected partners or cannot persuade their partners to use a
condom.
Management of STIs was based on clinical diagnosis and serologic
tests for herpes simplex virus type 2 (HSV-2) (Kamali 2003).
Peer education enlists members of a specific group to encourage ef-
fective behavioral change among their peers (Cornish 2009, Steen
2009). Its initial goal is usually to modify individuals’ knowledge,
attitudes and beliefs to bring about healthy behavior.
Structural interventions which mobilize sex workers to engage
in HIV prevention may address other factors, such as economic
security, reducing stigmatization, community-based organizing
(Ghose 2008) and rights-based advocacy (Wolffers 2003).
How the intervention might work
A decline in HIV prevalence in Cambodia occurred when rates
of consistent condom use during commercial sex rose from 53%
in 1997 to 96% in 2003 (Gorbach 2006); and in China, con-
sistent use of condoms resulted in a 70% reduction in HIV in-
fections (Wang 2009). Other countries with epidemics driven by
the sex work industry, such as Kenya and Uganda (Morris 2006),
Chile (Barrientos 2007) and India (Basu 2004), have experienced
declines in HIV prevalence when sex workers and their clients
used condoms consistently. Increasing condom use, however, de-
pends very much on condom availability (Bradley 2010). There-
fore, making condoms available in rooms where commercial sex
occurs is the most effective strategy to increase condom use (Egger
2000). In addition, consistent condom use was significantly greater
among males who perceived that some or all of the members of
their male social networks used condoms consistently (Barrington
2009). These results suggest that interventions to increase con-
dom use are more effective when implemented in conjunction
with social, network- and/or community-targeted interventions
that change the environment in which decisions about safe sex
behavior are taken.
Treatment for STIs was found to be more effective in reducing HIV
and STI transmission when combined with the consistent and
correct use of condoms (Laga 1994; Ghys 2001), suggesting that
behavioral interventions for primary prevention may also serve to
enhance the effectiveness of secondary prevention activities.
Peer education has resulted in substantial increases in STI and
HIV knowledge and use of condoms, and in the reduction of HIV
and STIs (Ford 2000).
Why it is important to do this review
Research in some countries has suggested that prevention projects
resulting in increased condom use during paid sex could signifi-
cantly reduce HIV transmission.
Various intervention strategies have been adopted to reduce HIV
transmission among sex workers and their clients in low- and mid-
dle-income countries, and their results suggest that these interven-
tions may play a significant role in preventing the spread of HIV;
however, the effectiveness of these strategies has not been assessed
rigorously through meta-analysis of randomised controlled trials.
Given the potential effectiveness and low cost of these interven-
tions, it is important to conduct a systematic review of their im-
plementation in low- and middle income countries.
O B J E C T I V E S
1. To evaluate the studies conducted on behavioral interventions
for reducing the transmission of HIV and STIs among sex work-
ers (male, female, and transgender) and their clients in low- and
middle-income countries.
2. To assess whether behavioral interventions such as condom use
and behavior modification are effective in reducing the HIV/STI
incidence and prevalence when the interventions are delivered in
sex worker settings.
3. To investigate behavioral interventions to reduce risk of HIV/
STIs transmission among sexual workers that have been tested in
RCTs.
M E T H O D S
Criteria for considering studies for this review
Types of studies
Randomized or quasi-randomized trials were considered for in-
clusion if they described behavioral interventions on any one of
the outcome measures specified below, occurring in sex worker
settings in low- and middle-income countries. Studies relevant to
outcome measures, whether primary or secondary outcomes were
included. The unit of randomization could be individual or clus-
ter level. Studies that were not eligible, for example studies that
did not randomly assign the sex workers in to the behavioral inter-
ventions and control groups, targeted not specifically sex workers
population, assessed other interventions rather than behavioral in-
terventions, or studies those not related to specified primary and
secondary outcome measures were excluded.
Low- and middle-income countries were defined based on World
Bank criteria and there are currently about 125 of these low- and
middle-income countries with populations of over one million;
7Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
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in 1997, their combined population was more than 4.89 billion
(World Bank).
Types of participants
Sex workers and their clients regardless of age, ethnicity, gender
identity, language and nationality are the target population:
Sex workers are defined as female, male and transgender, whether
adults or young people (including adolescents), who receive
money, goods or protection directly or indirectly in exchange for
indoor or outdoor sexual services, such as in a brothel, street or
home, either regularly or occasionally, and who may or may not
consciously define those activities as income-generating“.
Clients of sex workers were defined as female, male and transgender
adults or young people who give money, goods or protection in
exchange for sexual services to sex workers (defined above), either
regularly or occasionally.
Types of interventions
Intervention: Behavioral interventions, including social or policy
interventions to reduce the transmission of HIV in sex worker
settings. Behavioral interventions were defined in this systematic
review as interventions that aim to change not only individual be-
havior to prevent HIV infection but also peer and social norms,
including strategies such as community mobilization and struc-
tural and resource support, and through administrative or legal
decisions, such as promoting condom availability.
Control: Studies having no interventions or any other behavioral
interventions for preventing the spread of HIV among sex workers
and their clients.
Types of outcome measures
Primary outcomes
Change in biological variables for HIV/STI prevention among sex
workers and their clients, including:
a) HIV incidence
b) HIV prevalence
c) STI incidence
d) STI prevalence
Secondary outcomes
Change in self-reported or observed behavior, including:
a) Condom use (male/female)
b) HIV/STI-related knowledge
c) Types of sexual practice, such as vaginal, oral, or anal
d) Sexual risk behavior, such as having unprotected sex and mul-
tiple partners
e) Frequency of sexual encounters
f ) STIs treatment-seeking behavior
g) Psychosocial barriers to condom use
h) Drug and alcohol risk behavior
Search methods for identification of studies
Many different sources of published and unpublished research lit-
erature were searched for studies of behavioral interventions to
reduce HIV infection among sex workers and their clients. Re-
porting strategies of the effect of these interventions might not
be uniform, and there may be much grey literature and many lo-
cal publications reporting on this issue. The following databases
and conference proceedings were searched using a comprehensive
search strategy without restrictions on the language or country or
publication status of relevant trials. The date range of the search
was 01 January 1980 to the search date. The search was conducted
on 28 September 2010.
1) Electronic databases
Relevant databases were identified in consultation with the HIV/
AIDS Review Group Coordinator and the Trials Search Coordi-
nator for the Cochrane HIV/AIDS Group’s Trials Register, experts
in HIV/AIDS research and service projects working in low- and
middle-income countries, policy makers and healthcare adminis-
trators. This list served as the key document for the extraction of
data from electronic databases.
Cochrane Central Register of Controlled Trials (CENTRAL), the
Cochrane HIV/AIDS group specialized register, the Cochrane
Database of Systematic Reviews, MEDLINE, PsycINFO, Socio-
logical Abstracts, CINAHL, Dissertation Abstract International
(DAI), EMBASE, LILACS, BIOSIS, SciSearch, INDMED, Pro-
quest, and various South Asian abstracting databases were included
in the database list. The publication sites of the World Health Or-
ganization, the US Centers for Disease Control and Prevention,
and other international research and non-governmental organiza-
tions also appeared in the database list.
An extensive search strategy string was developed in consulta-
tion with the Trial Search Coordinator of the HIV/AIDS Review
Group. All possible keywords were included in the string to enable
an exhaustive electronic literature search. For further details see
the Appendices.
2) Hand searching
A hand search of key HIV/AIDS research journals was conducted
because many publications from low- and middle-income coun-
tries might not have appeared in electronic databases.
3) Personal communication
Key personnel and organizations working in HIV/AIDS interven-
tion programs in low- and middle-income countries were con-
tacted for published and unpublished references and data.
4) Conferences proceedings
Conference proceedings were searched for relevant abstracts. Con-
ferences included the Conference on Retroviruses and Oppor-
tunistic Infections (CROI), 1996-2010; International AIDS Con-
ference (IAC), 1985-2010; and International AIDS Society Con-
ference on HIV Pathogenesis, Treatment and Prevention (IAS),
2001-2009.
5) Cross-references
The bibliographies of studies identified by the procedures de-
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scribed above were further scrutinized to locate additional stud-
ies. The search strategy was iterative, in that bibliographies of the
included studies were searched for additional references.
Data collection and analysis
The methodology for data collection and analysis was based on
the Cochrane Handbook of Systematic Reviews of Interventions
(Higgins 2009).
Selection of studies
Using the inclusion criteria described above, two of the review
authors (WW and EO) independently assessed the potential stud-
ies that were identified as a result of the search strategy. Scrutiny
for inclusion was based on the type of study, type of participants,
type of interventions, and outcome measures. Any disagreements
were resolved through discussion and a third reviewer (RM) was
consulted. For all excluded studies a summary statement about
the exclusion reasons was made. Four authors (KS, RM, AK and
NH) who are experts were informed of the included studies and
conducted the data extraction independently.
Data extraction and management
Data was extracted independently using data collection forms. For
eligible studies, two review authors (WW and EO) extracted data
on trial characteristics including methods, participants, interven-
tions, and outcomes. Discrepancies were resolved through discus-
sion or by consulting with another review author (RM). Data
were entered into the Review Manager software (Revman 2008)
and checked for accuracy. When information regarding any of the
above was unclear, contact with the authors of the original reports
was attempted in order to elicit further details.
Assessment of risk of bias in included studies
Two review authors (WW and EO) independently assessed the
risk of bias for each study using the criteria outlined in the
Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2009). Discrepancies were resolved by discussion or by
involving an additional assessor (RM). Standard guidance was fol-
lowed for the assessment of the adequacy of methods to reduce
the risk of bias across seven domains:
1) Sequence generation (checking for possible selection bias)
For each included study the method used to generate the allocation
sequence was described in sufficient detail to allow an assessment
to be made of whether it would have produced comparable groups.
2) Allocation concealment (checking for possible selection bias)
For each included study the method used to conceal the allocation
sequence was described and a judgment made as to whether the
intervention allocation could have been foreseen in advance of or
during recruitment, or changed after assignment.
3) Blinding (checking for possible performance bias)
A description was provided of the methods used, if any, to blind
study participants and personnel from knowledge of which inter-
vention a participant received. Studies were judged to be at low
risk of bias if they were blind, or if the lack of blinding could
not have affected the results. Blinding was assessed separately for
different outcomes or classes of outcomes.
4) Incomplete outcome data (checking for possible attrition bias
through withdrawals, dropouts, protocol deviations)
For each included study, and for each outcome or class of outcome,
completeness of the data was assessed including checking attrition
and exclusions was noted, along with the numbers included in
the analysis at each stage (compared with the total number of
randomized participants), reasons for attrition or exclusions where
reported, and whether missing data were balanced across groups
or were related to outcomes. Where sufficient information was
reported, or was supplied by the trial authors, missing data was
included in the analyses.
5) Selective reporting bias
For each included study the possibility of selective outcome re-
porting bias was investigated and a conclusion reported.
6) Other sources of bias
For each included study all other possible sources of bias, includ-
ing study design and early trial cessation due to data-dependent
processes or extreme baseline imbalance were reported.
7) Overall risk of bias
Explicit judgments were made about whether studies were at high
risk of bias, according to the criteria given in the Handbook
(Higgins 2009). With reference to (1) to (6) above, the likely mag-
nitude and direction of the bias and its likely impact on the find-
ings was assessed and reported.
Measures of treatment effect
1) Dichotomous data
For dichotomous data, results are presented as summary risk ratios
(RR) with a 95% Confidence Interval (CI).
2) Continuous data
For continuous data, the mean difference (MD) was used if out-
comes were measured in the same way among trials. Standardized
mean differences were used to combine trials that measured the
same outcome with different methods.
Unit of analysis issues
All RCTs, cluster-RCTs, and quasi-RCTs were identified.
Dealing with missing data
For included trials, attrition levels were noted and the impact of
including trials with high levels of missing data in the overall as-
sessment of the treatment effect was checked through a sensitivity
analysis. For all outcomes analyses were conducted on an inten-
tion-to-treat basis. The denominator for each outcome in each
trial was the number randomized minus any participants whose
outcomes were known to be missing.
Assessment of heterogeneity
Heterogeneity amongst trials was tested using an I2 statistic in
each analysis. A value of I2=0% indicates no observed heterogene-
ity. Where substantial heterogeneity (I2 >50%) was identified, a
prespecified subgroup analysis was conducted. Subgroup analyses
were planned based on the extent of control for selection bias.
However, subgroup analysis considered the effects of different du-
9Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
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Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
rations of follow-up or different routes that were not included due
to a lack of available data.
Assessment of reporting biases
Where reporting bias was suspected (see ”Selective reporting bias“
above), attempts were made to contact study authors, asking them
to provide missing outcome data. Where this was not possible and
the missing data were thought to introduce serious bias impact
of including such studies in the overall assessment of results was
explored through sensitivity analysis.
Data synthesis
A meta-analysis was conducted using the Review Manager soft-
ware (Revman 2008). Fixed-effect inverse variance meta-analysis
was used for combining data where trials were examining the same
intervention and the trials’ populations and methods were judged
sufficiently similar. Where heterogeneity between trials’ treatment
effects was suspected, random-effect meta-analysis was used. The
criteria of the Grading of Recommendations Assessment, Devel-
opment and Evaluation (GRADE) to evaluate the quality of the
evidence by outcome was performed (Guyatt 2008).
Subgroup analysis and investigation of heterogeneity
Subgroup analysis was conducted for the primary outcomes of
HIV incidence, HIV prevalence, STI incidence and STI preva-
lence. For the fixed-effect meta-analysis, a planned subgroup anal-
ysis was conducted, classifying whole trials by interaction tests as
described by Deeks (Deeks 2001).
Sensitivity analysis
Sensitivity analyses were not performed.
Results
R E S U L T S
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
See Characteristics of included studies; Characteristics of excluded
studies
A total of 2667 citations published between 1980 and 2010 were
obtained. Of these, 53 potential studies were identified for consid-
eration. Overall, 13 trials with 8,698 participants were analysed.
Of these, two studies in Madagascar (Feldblum 2005, Hoke 2007)
used the same population, as did two studies in Mexico (Patterson
2006, Patterson 2008). Two studies using previously published
data (Hoke 2007, Patterson 2008) were included because they
included outcomes, which were not previously reported. The re-
maining 40 not eligible studies were excluded (Figure 1).
10Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
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Figure 1. Study flow diagram.
11Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Seven RCTs (Ghys 2001, Ray 2001, Feldblum 2005-Hoke 2007,
Patterson 2006- Patterson 2008, Wechsberg 2006, Markosyan
2010 and Sherman 2010), two cluster-RCTs (Fontanet 1998
and Gutierrez 2010) and four quasi-RCTs (Basu 2004, Li 2006,
Swendeman 2009 and Chiao 2009) met the inclusion criteria.
The process of randomizations in the two cluster-RCTs (Fontanet
1998 and Gutierrez 2010) was done by using clusters rather than
individuals. However, we nevertheless included them because in-
dividual data was used as the unit of data analysis.
Seven out of 13 trials were conducted in Asia (four trials in India
(Basu 2004, Swendeman 2009, Gutierrez 2010, and Sherman
2010), one in Thailand (Fontanet 1998), and one in China (Li
2006), one in the Philippines (Chiao 2009), and one in Armenia
(Markosyan 2010). Four trials were evaluated in Africa (one in
Madagascar (Feldblum 2005-Hoke 2007), one in Cote d’Ivore
(Ghys 2001), one in Zimbabwe (Ray 2001), and one in South
Africa (Wechsberg 2006). The remaining one trial was conducted
in Latin America (Patterson 2006-Patterson 2008).
Primary outcomes were identified in seven trials (Patterson 2008,
Gutierrez 2010, Feldblum 2005-Hoke 2007, Ray 2001, Fontanet
1998, Ghys 2001, and Li 2006). Of these, three trials measured
HIV incidence (Patterson 2008, Ghys 2001, and Ray 2001),
two trials measured the incidence of STIs ( Patterson 2008 and
Fontanet 1998) and four trials measured the prevalence of STIs
(Gutierrez 2010, Feldblum 2005-Hoke 2007, Ghys 2001 and Li
2006). There were no trials that measured HIV prevalence. Sec-
ondary outcomes were identified in all studies.
Although most trials provided a follow-up period of at least 6
months to assess outcomes (Ghys 2001, Feldblum 2005, Patterson
2008, Markosyan 2010, Sherman 2010) the duration of the fol-
low-up varied across studies. The shortest was a 3-month trial that
occurred in Thailand (Fontanet 1998) whereas the longest follow-
up was up to three years in a trial conducted in India (Gutierrez
2010).
Interventions
1) Social cognitive theory
Social cognitive theory identifies human behavior as a personal,
behavior, and the environment factors interact (Bandura 1986).
Person and environment interaction involves human beliefs and
cognitive competencies. Social influences and structures within the
environment were developed and modified by this interaction. The
third interaction, between the environment and behavior, involves
a person’s behavior determining the aspects of their environment.
The behavior also being modified by that environment. Despite
behavior may varies from situation to situation, behavior is not
controlled by situation itself rather than person. It means different
responses can come from different people or from the same person
at different times (Jones 1989). Therefore, this theory is useful to
understand and predict both individual and group behavior, and
identify strategies in which behavior can be changed.
2) Community empowerment
Community empowerment (also called community organization,
-mobilization, or -action research) is a strategy used in public
health, behavioral sciences, and social movements, that can mo-
bilize people for recognizing structural barriers to improve health,
and empower them to change these barriers. This method is distin-
guished from behavioral change, because it addresses behaviours
through the active involvement of community members to de-
sign, execute, and evaluate their empowerment projects. Com-
munity involvement in the evaluation directly contributes to ca-
pacity-building and increased awareness in the target community
(Stevens 1998).
3) Microenterprise
Microenterprise intervention empowers individuals through mi-
cro-finance, teaching basic literacy, and training in specific eco-
nomic livelihoods (e.g., tailoring, computer literacy). Microenter-
prise programs (e.g., micro-finance, micro-credit) have been re-
ported effective in increasing women’s economic well-being, in
reducing interpersonal violence, in increasing reproductive health
decision-making power, and broaden their role in household de-
cision making (Kim 2007, Hashemi 1996, Schuler 1997).
4) Peer education
This intervention provides training and support to community
members and is usually conducted to effect change at both the
individual and the group level, with the aim to modify the person’s
knowledge, attitudes, beliefs, or behaviours. This strategy may
effect change by modifying norms that contribute to individual
change as well as changes in programs and policies.
5) Manager training
Manager training focuses on providing specialized, HIV-based in-
formation and education, reinforcing positive STI prevention be-
havior that addresses the managerial class, to increase their influ-
ence through providing positive reinforcement of their employee’s
safer sex practices.
6) Promotion of female condom use
This intervention promotes the use of female condoms properly,
enhancing condom self-efficacy and negotiation skills and knowl-
edge of HIV/STI transmission, HIV/STI risk assessment, and safer
sex options. Early female condom introduction efforts were tar-
geted to FSWs, because they are at high risk for HIV and other
STIs and have an obvious need for a female- initiated method of
protection. Introduction of the female condom has been more suc-
cessful in shorter-term programs, particularly among sex workers
and members of women’s groups (PATH and UNFPA 2006).
7) STI screening
The systematic strategy of providing STI antibody testing to a
population of apparently healthy people without signs and symp-
toms of that disease for the purpose of detecting the number of
people (or blood samples) infected with an STI. The primary aim
12Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
is not to diagnose STI in a specific person. Screening programs
might direct additional resources to groups with the most risky
sexual behavior -e.g., sex workers, their clients, migrant workers,
and those attending STI clinics (WHO 2006).
8) VCT
VCT provides individuals with knowledge of their HIV infection
status, risk assessment, and promotes risk reduction. This inter-
vention may effective in reducing the risk of further transmission
of HIV by promoting safer sex (Nelson 2007).
Risk of bias in included studies
Assessment of the risk of bias in the included studies is summarized
in Figure 2 and Figure 3.
13Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 2. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.
14Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 3. Risk of bias graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies.
Allocation
Generation of the randomisation sequence was judged to be at low
risk of bias for all trials. Allocation concealment was judged to be
at low risk of bias in 13 trials and unclear in four trials (Ghys 2001,
Li 2006, Wechsberg 2006, Gutierrez 2010). Descriptions which
included the following details were accepted as being adequate for
concealment: a random number table (Fontanet 1998, Basu 2004
and Swendeman 2009), the flip of a coin (Markosyan 2010), a
computer generated random allocation list (Feldblum 2005-Hoke
2007, Patterson 2006-Patterson 2008), opaque sealed envelopes
(Sherman 2010), numbered sealed envelopes (Ray 2001), and
numbers placed in a box (Chiao 2009).
Blinding
Of the included studies only three trials (Feldblum 2005-Hoke
2007, Markosyan 2010, Sherman 2010) were judged to be at low
risk of bias due to adequate blinding.
Incomplete outcome data
The proportion of participants in each intervention arm for whom
an outcome was not available was reported. Five trials (Basu
2004, Feldblum 2005-Hoke 2007, Patterson 2008, Chiao 2009,
Markosyan 2010) were judged to be at high risk of bias due to
moderate missing data that had the potential to alter the results,
while most of the trials did not address the reasons for the incom-
plete outcome data.
Selective reporting
Eleven trials were assessed as being free of selective reporting bias.
The remaining two studies (Gutierrez 2010, Sherman 2010) did
not present the study outcome completely and were judged to be
at high risk of bias.
Other potential sources of bias
Three studies (Wechsberg 2006, Li 2006, Chiao 2009) were
judged to be at high risk of bias due to an imbalance of base-
line characteristics between the intervention group and the control
group.
Effects of interventions
See: Summary of findings for the main comparison Social
cognitive theory compared to standard counseling for promotion
of condom use; Summary of findings 2 Social cognitive theory
for promotion of condom use compared to no intervention;
Summary of findings 3 Promotion of female and male condom
compared to promotion of male condom; Summary of findings
4 VCT compared to standard care of STI for increasing condom
use
Comparison 1. Social cognitive theory versus standard care
(Analysis 1)
This comparison included two trials (Wechsberg 2006 and
Patterson 2006-Patterson 2008) comprising 1017 FSWs.
1. Primary outcomes
One trial conducted in Mexico (Patterson 2008) reported HIV
incidence. After a 6-month follow-up period, the risk ratio of HIV
incidence was 0.12 (95% CI 0.01 to 2.22; Analysis 1.1) indicating
a reduction in HIV incidence. Patterson 2008 also reported STI
15Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
incidence and showed a significant decrease in the cumulative
incidence of any STIs among the intervention group (RR 0.57,
95% CI 0.34 to 0.96; Analysis 1.2) compared to the control group.
2. Secondary outcomes
Two trials (Wechsberg 2006, Patterson 2008) reported consistent
condom use and one trial (Patterson 2006) reported the mean
frequency of condom use. Patterson 2006 and Patterson 2008 re-
ported sexual activity outcomes (e.g. total protected sex, had vagi-
nal sex, had anal sex, and had oral sex), and two trials (Patterson
2006, Wechsberg 2006) reported drug and alcohol use. However,
heterogeneity of study designs prevented any meta-analyses of con-
sistent condom use and alcohol risk behavior variables.
There were no differences in the increase in consistent condom
use (Analysis 1.3; Analysis 1.4; Analysis 1.5), in changes in FSWs
sexual activities (Analysis 1.6), or in injecting drug use and alco-
hol risk behavior (Analysis 1.7; Analysis 1.8), indicating that the
intervention had no impact. However, this intervention did show
a decrease in drug use among FSW (RR 0.65, 95% CI 0.36 to
1.16, p for heterogeneity=0.15, I2=52%; Analysis 1.9).
Comparison 2. Social cognitive theory versus no intervention
(Analysis 2)
Only one trial of 120 FSWs examined this comparison (
Markosyan 2010).
1. Primary outcomes
None reported.
2. Secondary outcomes
Consistent condom use, HIV knowledge, and psychosocial medi-
ators of HIV prevention behavior were assessed. However, social
cognitive theory was found not to increase reported condom use,
including barriers to condom use and condom use self-efficacy, or
HIV-related knowledge (Analysis 2.1; Analysis 2.2; Analysis 2.3)
Comparison 3. Community empowerment versus standard
care (Analysis 3)
There were three trials assessing this comparison (Basu 2004,
Swendeman 2009, and Gutierrez 2010) involving a total of 3,858
FSWs.
1. Primary outcomes
One trial reported the prevalence of STIs (Gutierrez 2010). How-
ever, after a follow-up assessment the risk ratio of syphilis and
HSV-2 were 1.26 and 1.38, respectively (Analysis 3.1), indicating
that there was no effect in reducing the prevalence of STIs. More-
over, none of the studies reported on the other primary outcomes.
2. Secondary outcomes
Both trials (Basu 2004, Gutierrez 2010) reported on consistent
condom use with clients and HIV-related knowledge. One trial
(Gutierrez 2010) reported consistent condom use with regular
partners, one trial (Basu 2004) reported changes in 100% condom
use and changes in any condom use, condom availability, type of
sexual practices, and drug and alcohol use. One trial (Gutierrez
2010) reported HIV testing.
A trial in India (Gutierrez 2010) was successful at reduction in
non-condom use with regular partners over a 3-year follow-up
period (RR 0.55, 95% CI 0.48 to 0.64; Analysis 3.2). However,
a community empowerment intervention showed no increase in
condom use with clients (Analysis 3.3; Analysis 3.4; Analysis 3.5),
HIV-related knowledge (Swendeman 2009; Analysis 3.6), HIV
testing (Gutierrez 2010; Analysis 3.7), risk management skills and
protective factors (Swendeman 2009; Analysis 3.8).
Comparison 4. Microenterprise plus education intervention
versus education alone (Analysis 4)
There was only one trial (Sherman 2010) consisting of 128 FSWs,
which assessed this comparison.
1. Primary outcomes
None.
2. Secondary outcomes
There was no increase in condom use after a 6 month follow-up
period (Analysis 4.1). This trial reported that the mean number
of sex partners (MD -6.90, 95% CI -10,02 to -3,78) and number
of exchange sex partners (MD -2.00, 95% CI -3.01 to -0.99) was
smaller for those who experienced community empowerment plus
education rather than education alone (Analysis 4.2).
Comparison 5. Peer education versus standard care (Analysis
5)
There was only one trial (Chiao 2009) of 980 FSWs that assessed
the effect of peer education compared with standard care.
1. Primary outcomes
This study did not report primary outcomes.
2. Secondary outcomes
This intervention had no effect on self-reported consistent con-
dom use (Analysis 5.1), HIV-related knowledge (Analysis 5.2) or
perceived need for HIV testing (Analysis 5.3). However, a peer-
led intervention was effective and increased self-regulatory factors,
such as perceived control over risk of HIV acquisition (RR 0.74,
95% 0.84 to 0.99; Analysis 5.4) and perceived severity (Analysis
5.5), whether in relation to the chance of acquiring HIV (MD -
1.47, 95% CI -1.83 to -1.11) or worry about acquiring HIV (MD
-1.02, 95% -1.50 to -1.00).
Comparison 6. Peer education plus clinic-based counselling
versus peer education only (Analysis 6)
There was one trial (Feldblum 2005, Hoke 2007) involving 1000
FSWs.
1. Primary outcomes
The addition of clinic-based counselling to a peer education in-
tervention decreased the prevalence of STIs (Analysis 6.1), partic-
ularly Chlamydia at 6-month follow-up (RR 0.70, 95% CI 0.50
to 0.97) and any STIs at 6-month follow-up (RR 0.78, 95% CI
0.65 to 0.93), but the intervention was found to have no effect in
reducing the prevalence of all types of STIs after 12 months’ and
18 months’ follow-up. Other primary outcomes were not assessed
by this intervention.
2. Secondary outcomes
Feldblum 2005 reported that FSWs who were administered peer
education plus clinic-based counselling were less likely to report
overall male condom use, whether with clients (Analysis 6.2) or
16Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
non-paying partners (Analysis 6.3) compared with FSWs assigned
to the peer education intervention only. In addition, Hoke 2007
reported there was no increase in the use of female condoms after
12 months’ and 18 months’ follow-up (Analysis 6.4), indicating
that there was no effect of this intervention. Hoke 2007 also found
that FSWs assigned to the combined interventions were less likely
to use male or female condoms with clients (Analysis 6.5) and
non-paying partners (Analysis 6.6).
Comparison 7. Peer education plus manager training versus
standard care (Analysis 7)
One study (Chiao 2009) of 980 FSWs.
1. Primary outcomes
None of the primary outcomes were reported.
2. Other outcomes
This trial examined consistent condom use, HIV-related knowl-
edge, HIV testing and protective behavior, such as perceived con-
trol over AIDS and perceived AIDS severity. However, the inter-
vention had no effect in increasing condom use (Analysis 7.1) and
HIV-related knowledge (Analysis 7.2). At a 3-month follow up
assessment, manager training in addition to peer education in-
creased the likelihood of seeking HIV testing by 67% (95% CI
59% to 73%; Analysis 7.3).
Comparison 8. Manager training versus standard care (Anal-
ysis 8)
One study (Chiao 2009) of 980 FSWs.
1. Primary outcomes
None.
2. Secondary outcomes
This trial reported on consistent condom use, HIV-related knowl-
edge, HIV testing and protective behavior, such as perceived AIDS
control (Analysis 7.4) and severity (Analysis 7.5). The interven-
tion had no effect on condom use (Analysis 8.1), HIV-related
knowledge (Analysis 8.2), and the likelihood of having an HIV
test (Analysis 8.3), and had not reduce the AIDS perceived control
(Analysis 8.4). However, the manager training intervention was
found to increase the FSWs perceived severity of acquiring HIV
(MD -0.43, 95% CI -0.80 to -0.06; Analysis 8.5).
Comparison 9. Promotion of female and male condom versus
promotion of male condom (Analysis 9)
Two studies (Fontanet 1998; Ray 2001) involving 653 FSWs.
1. Primary outcomes
Ray 2001 reported HIV incidence. After a 3-month follow-up,
the risk ratio of HIV incidence was 0.07 (95% CI 0.00 to
1.38; Analysis 9.1) indicating a large reduction in HIV inci-
dence. Fontanet 1998 reported a decrease in the incidence of STIs
(Analysis 9.2), in particular, the incidence of chlamydia and gon-
orrhoea (RR 0.71, 95% CI 0.52 to 0.98 and RR 0.63, 95% CI
0.45 to 0.88, respectively).
2. Secondary outcomes
Two trials (Fontanet 1998, Ray 2001) reported on consistent fe-
male and male condom use. Meta-analyses showed a decrease in
male condom at 3-month follow-up (RR 0.83, 95% CI 0.65 to
1.05, P for heterogeneity=0.09, I2=65%; Analysis 9.3) and over-
all non-usage of the female (RR 0.12, 95% CI 0.09 to 0.17, p=
<0.001, P for heterogeneity=0.78, I2=0%; Analysis 9.4). A de-
crease was also seen in non-usage of the female condom at 24-
months follow-up (RR 0.15, 95% CI 0.09 to 0.28; Analysis 9.5),
but there was no effect for the male condom at 24-months follow-
up (RR 0.91, 95% CI 0.82 to 1.02; Analysis 9.6).
Comparison 10. Intensive STI screening versus basic STI
screening (Analysis 10)
One study (Ghys 2001) including 542 FSWs.
1. Primary outcomes
After a 6-month follow-up period, the risk ratio of HIV incidence
was 0.65 (95% CI 0.24 to 1.73; Analysis 10.1) indicating a reduc-
tion in HIV incidence. This trial also reported a positive effect of
intensive STI screening in reducing STI prevalence at 6-months
follow-up (Analysis 10.2) compared with basic STI screening. In
particular, it reduced the prevalence of gonorrhoea and chlamydia
trachomatis (RR 0.38, 95% CI 0.19 to 0.77, and RR 0.23, 95%
CI 0.07 to 0.79, respectively). Other primary outcomes were not
reported.
2. Secondary outcomes
There was no increase in consistent condom use after a 6-month
follow-up assessment (RR 1.04, 95% CI 0.96 to 1.13; Analysis
10.3).
Comparison 11. Voluntary HIV counselling and testing versus
the standard care of STIs (Analysis 11)
We identified one trial (Li 2006) involving 400 FSWs.
1. Primary outcome
This trial reported a positive effect of VCT compared with stan-
dard STI management in reducing STI prevalence at 6-months
follow-up (Analysis 11.1). In particular, the intervention was ef-
fective in reducing the prevalence of genital warts (RR 0.22, 95%
CI 0.05 to 0.98). Other primary outcomes were not reported.
2. Secondary outcomes
This trial assessed the effect of the intervention on consistent
condom use and HIV/STI related knowledge. However, after 6-
months follow-up, there was no increase in either consistent con-
dom use (RR 2.05, 95% CI 1.48 to 2.85; Analysis 11.2) or HIV/
STI related knowledge (RR 1.28, 95% CI 0.81 to 2.04; Analysis
11.3).
17Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
AD
DI
TI
ON
AL
SU
MM
AR
YO
FF
IN
DI
NG
S[E
xpla
nati
on]
Socialcognitivetheoryforpromotionofcondomusecomparedtonointerventionforsexworkers
Patientorpopulation:sexworkers
Settings:low-andmiddle-incomecountries
Intervention:Socialcognitivetheoryforprom
otionofcondom
use
Comparison:no
intervention
Outcomes
Illustrative
comparativerisks*
(95%CI)
Relativeeffect
(95%CI)
NoofParticipants
(studies)
Qualityoftheevidence
(GRADE)
Com
ments
Assumed
risk
Correspondingrisk
nointervention
Socialcognitivetheory
forpromotionofcondom
use
Consistentcondom
use
byFSWswithclientsat
6-month
Studypopulation
RR0.89
(0.61to1.30)
98 (1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
560per1000
498per1000
(342
to728)
Mediumriskpopulation
560per1000
498per1000
(342
to728)
Consistentcondom
use
byFSWswithclientsin
thepast7-day
Studypopulation
RR0.92
(0.68to1.24)
98 (1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
660per1000
607per1000
(449
to818)
Mediumriskpopulation
660per1000
607per1000
(449
to818)
18Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Consistentapplicationof
condombyFSWs
Studypopulation
RR0.65
(0.23to1.85)
98 (1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
160per1000
104per1000
(37to296)
Mediumriskpopulation
160per1000
104per1000
(37to296)
HIV
knowledgeamong
FSWsat6-month
Studypopulation
RR2.08
(0.4to10.85)
98 (1study)
⊕©
©©
verylow
1,2,5,6,7
40per1000
83per1000
(16to434)
Mediumriskpopulation
Psychosocialbarriersto
condom
use
among
FSWsat6-month
Studypopulation
RR0.83
(0.36to1.93)
98 (1study)
⊕⊕
⊕©
moderate
1,2,3,4,5
200per1000
166per1000
(72to386)
Mediumriskpopulation
200per1000
166per1000
(72to386)
Psychosocialbarriersto
condom
use
self-effi-
cacy
amongFSWsat6-
month
Studypopulation
RR1.56
(0.85to2.89)
98 (1study)
⊕©
©©
verylow
1,2,5,6,7
240per1000
374per1000
(204
to694)
Mediumriskpopulation
19Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
240per1000
374per1000
(204
to694)
*The
basisfortheassumedrisk
(e.g.themediancontrolgroupriskacross
studies)isprovided
infootnotes.Thecorrespondingrisk(and
its95%confidence
interval)isbasedon
the
assumedriskinthecomparison
groupandtherelativeeffectoftheintervention(andits95%CI).
CI:Confidenceinterval;RR:Riskratio;
GRADEWorkingGroupgradesofevidence
Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheestimate.
Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
Verylowquality:Weareveryuncertainabouttheestimate.
1Noseriouslimitations:Allocationconcealmentwasjudgedtobeat’’low
riskofbias‘‘
inthistrial.
2Singlestudy.
3Noseriousindirectness:Resultislikelytobereliable.
4Seriousimprecision:The95%CIofestimatecrossesthelineofno
effect.
5Biaswasjudgedtobeat’’low
risk‘‘inthistrial.
6Serious
indirectness:Thereisconsiderablevariabilityintheeffectofcontrolwhich
makes
extrapolationofresulttoothersetting
unreliable.
7Veryseriousimprecision:The95%CIofestimateincludesappreciablebenefittocontrolgroup
overinterventiongroup.
20Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Promotion
offemaleand
malecondomcomparedtoprom
otionofmalecondomforsexworkers
Patientorpopulation:sexworkers
Settings:low-andmiddle-incomecountries
Intervention:Promotionoffemaleandmalecondom
Comparison:prom
otionofmalecondom
Outcomes
Illustrative
comparativerisks*
(95%CI)
Relativeeffect
(95%CI)
NoofParticipants
(studies)
Qualityoftheevidence
(GRADE)
Com
ments
Assumed
risk
Correspondingrisk
promotionofmalecon-
dom
Promotionoffemaleand
malecondom
HIV
incidence
among
FSWsat3-month
Studypopulation
RR0.07
(0to1.38)
149
(1study)
⊕⊕
©©
low
1,2,3,4,5
60per1000
4per1000
(0to83)
Lowriskpopulation
Chlamydia
incidence
amongFSWsat3-month
Studypopulation
RR0.71
(0.52to0.98)
504
(1study)
⊕⊕
⊕⊕
high1
,2,3,5,6
282per1000
200per1000
(147
to276)
Mediumriskpopulation
282per1000
200per1000
(147
to276)
Gonorrhoea
incidence
amongFSWsat3-month
Studypopulation
RR0.63
(0.45to0.88)
504
(1study)
⊕⊕
⊕⊕
high1
,2,3,5,6
21Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
275per1000
173per1000
(124
to242)
Mediumriskpopulation
275per1000
173per1000
(124
to242)
Consistentmalecondom
useat3-month
Studypopulation
RR0.88
(0.83to0.92)
572
(2studies)
⊕⊕
⊕⊕
high3
,6,7,8,9
968per1000
852per1000
(803
to891)
Mediumriskpopulation
913per1000
803per1000
(758
to840)
Consistentfemalecon-
domuse
byFSWsat3-
month
Studypopulation
RR0.12
(0.09to0.17)
564
(2studies)
⊕⊕
⊕⊕
high3
,6,7,9,10
968per1000
116per1000
(87to165)
Mediumriskpopulation
913per1000
110per1000
(82to155)
Consistentfemalecon-
domusebyFSWsat24-
month
Studypopulation
RR0.15
(0.09to0.28)
128
(1study)
⊕⊕
⊕⊕
high1
,2,3,5,6
950per1000
143per1000
(86to266)
Lowriskpopulation
147per1000
22per1000
(13to41)
22Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Consistentmalecondom
useat24-month
Studypopulation
RR0.91
(0.82to1.02)
128
(1study)
⊕⊕
⊕©
moderate
1,2,3,5,11
950per1000
865per1000
(779
to969)
Lowriskpopulation
868per1000
790per1000
(712
to885)
*The
basisfortheassumedrisk
(e.g.themediancontrolgroupriskacross
studies)isprovided
infootnotes.Thecorrespondingrisk(and
its95%confidence
interval)isbasedon
the
assumedriskinthecomparison
groupandtherelativeeffectoftheintervention(andits95%CI).
CI:Confidenceinterval;RR:Riskratio;
GRADEWorkingGroupgradesofevidence
Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheestimate.
Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
Verylowquality:Weareveryuncertainabouttheestimate.
1Noseriouslimitations:Allocationconcealmentwasjudgedtobeat’’low
riskofbias‘‘
inthistrial.
2Singlestudy.
3Noseriousindirectness:Resultislikelytobereliable.
4Veryseriousimprecision:The95%CIofestimateiswideandcrossesthelineofno
effect.
5Biaswasjudgedtobeat’’low
risk‘‘inthistrial.
6Noseriousimprecision:The95%CIofestimateincludesappreciablebenefittointerventiongroupovercontrolgroup.
7Noseriouslimitations:Allocationconcealmentwasjudgedtobeat’’low
riskofbias‘‘
intwotrials.
8Noseriousinconsistency:Mayrepresentsubstantialheterogeneity(65%).
9Biaswasjudgedtobeat’’low
risk‘‘intwotrials.
10Noseriousinconsistency:Heterogeneity(0%)mightnotbeimportant.
11Seriousimprecision:The95%CIofestimatecrossesthelineofno
effect.
23Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
VCTcomparedtostandardcareofSTIforincreasingcondomuseforsexworkers
Patientorpopulation:sexworkers
Settings:low-andmiddleincomecountries
Intervention:VCT
Comparison:standardcareofSTIforincreasing
condom
use
Outcomes
Illustrative
comparativerisks*
(95%CI)
Relativeeffect
(95%CI)
NoofParticipants
(studies)
Qualityoftheevidence
(GRADE)
Com
ments
Assumed
risk
Correspondingrisk
standardcareofSTIfor
increasingcondomuse
VCT
Syphilis
prevalence
amongFSWsat6-month
Studypopulation
RR0.52
(0.23to1.18)
278
(1study)
⊕©
©©
verylow
1,2,3,4,5
109per1000
57per1000
(25to129)
Mediumriskpopulation
110per1000
57per1000
(25to130)
Gonorrhoeaprevalence
amongFSWsat6-month
Studypopulation
RR0.83
(0.4to1.74)
278
(1study)
⊕©
©©
verylow
1,2,3,4,5
102per1000
85per1000
(41to177)
Mediumriskpopulation
102per1000
85per1000
(41to177)
Chlamydia
prevalence
amongFSWsat6-month
Studypopulation
RR0.67
(0.4to1.13)
278
(1study)
⊕©
©©
verylow
1,2,3,4,5
24Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
212per1000
142per1000
(85to240)
Mediumriskpopulation
212per1000
142per1000
(85to240)
Trichomonas
preva-
lenceamongFSWsat6-
month
Studypopulation
RR0.52
(0.23to1.18)
278
(1study)
⊕©
©©
verylow
1,2,3,4,5
109per1000
57per1000
(25to129)
Mediumriskpopulation
110per1000
57per1000
(25to130)
Genital
warts
preva-
lenceamongFSWsat6-
month
Studypopulation
RR0.22
(0.05to0.98)
278
(1study)
⊕⊕
©©
low
1,2,3,5,6
66per1000
15per1000
(3to65)
Mediumriskpopulation
66per1000
15per1000
(3to65)
Consistentcondom
use
byFSWswithclientsat
6-month
Studypopulation
RR2.05
(1.48to2.85)
278
(1study)
⊕©
©©
verylow
1,2,5,7,8
255per1000
523per1000
(377
to727)
Lowriskpopulation
255per1000
523per1000
(377
to727)
25Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
HIV/STI
knowledgeam
ongFSWs
at6-month
Studypopulation
RR1.28
(0.81to2.04)
278
(1study)
⊕©
©©
verylow
1,2,5,7,8
182per1000
233per1000
(147
to371)
Lowriskpopulation
182per1000
233per1000
(147
to371)
*The
basisfortheassumedrisk
(e.g.themediancontrolgroupriskacross
studies)isprovided
infootnotes.Thecorrespondingrisk(and
its95%confidence
interval)isbasedon
the
assumedriskinthecomparison
groupandtherelativeeffectoftheintervention(andits95%CI).
CI:Confidenceinterval;RR:Riskratio;
GRADEWorkingGroupgradesofevidence
Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheestimate.
Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
Verylowquality:Weareveryuncertainabouttheestimate.
1Seriouslimitations:Allocationconcealmentwasjudged’’unclear‘‘
inthistrial.
2Singlestudy.
3Noseriousindirectness:Resultislikelytobereliable.
4Seriousimprecision:The95%CIofestimatecrossesthelineofno
effect.
5Biaswasjudgedtobeat’’highrisk‘‘inthistrial.
6Noseriousimprecision:The95%CIofestimateincludesappreciablebenefittointerventiongroupovercontrolgroup.
7Serious
indirectness:Thereisconsiderablevariabilityintheeffectofcontrolwhich
makes
extrapolationofresulttoothersettings
unreliable.
8Veryseriousimprecision:The95%CIofestimateincludeappreciablebenefittocontrolgroupoverinterventiongroup.
26Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D I S C U S S I O N
Summary of main results
The current review addressed a number of HIV behavioral pre-
vention interventions intended to reduce the transmission of HIV
among FSWs in low- and middle-income countries. The review
used comprehensive search strategies encompassing both pub-
lished and non-published studies. In addition, strict inclusion cri-
teria were followed to ensure that the review was focused on behav-
ioral interventions among sex workers. The review’s conclusions
are weakened by the small number and size of the potential trials
and by the insufficiency of the reported data for the pre-specified
primary and secondary outcomes.
Thirteen trials were identified which fulfilled the inclusion crite-
ria for this review, involving 8,698 participants. Of the interven-
tions assessed, seven studies identified the primary outcomes but
only three trials examined HIV incidence. Moreover, there was
no strong evidence that these interventions reduced HIV preva-
lence. Nonetheless, results of meta-analyses of primary outcomes
found that the interventions did have an effect in reducing HIV
incidence among FSWs assigned to a social cognitive intervention
compared with those received standard counselling for HIV/STIs
(Patterson 2008) and interventions promoting the use of female
and male condoms were more effective compared than those that
promoted male condoms only (Ray 2001). Furthermore, other
primary outcomes, such as the incidence of STIs, were assessed by
various interventions such as:
• Social cognitive theory, which was found to be effective in
reducing the incidence of any STIs in India by 43% (Patterson
2008);
• Promotion of condom use, which reduced gonorrhoea and
chlamydia incidence in Thailand by 37% and 29%, respectively
(Fontanet 1998)
• Peer education intervention in addition to clinic-based
counselling conducted which reduced prevalence of chlamydia
and of any STIs by 30% and 20%, respectively in Madagascar
(Feldblum 2005)
• Intensive STI screening, which reduced HIV incidence by
35%, and chlamydia trachomatis and gonorrhoea prevalence by
77% and 62%, respectively in Cote d’Ivore (Ghys 2001)
• VCT intervention, which led to a 78% reduction in
prevalence of genital warts among FSWs in China (Li 2006)
• Prevalence of STIs was also reported by a community
empowerment intervention in India (Gutierrez 2010), but no
intervention effect was found.
Meta-analyses also were performed for two secondary outcomes;
changes in behavior outcomes such as consistent condom use,
including female and male condom use; and drug use risk be-
havior. These meta-analyses showed strong effects of the promo-
tion of condom use in intervention and control groups, includ-
ing increases in female condom use rather than male condom use.
However, this was positively correlated with increased condom
use by clients, a finding not repeated in other results from the
meta-analysis. There was a difference between social cognitive the-
ory and standard care in the reduction of illicit drug use among
FSWs. Substantial heterogeneity (I2>50%) in this review were
identified in two meta-analyses assessed consistent condom use
through community empowerment intervention (81%; Analysis
3.3) and through promotion of female and male condom use
(65%; Analysis 3.4) indicated that variability in methodological,
implementation of interventions, settings or populations may be
differ. No observed heterogeneity were observed among studies
whether evaluated consistent condom use through social cognitive
intervention (Analysis 1.3) or through promotion of condom use
(Analysis 9.4) indicated studies contributed for meta-analysis is a
similar way.
The effectiveness of behavioral interventions for other secondary
outcomes was analysed. Results were
• A positive increase in the rate of consistent use of condoms
with regular partners by 45% as a result of a community
empowerment intervention (Gutierrez 2010)
• The addition of an education intervention to a
microenterprise intervention conducted in India was associated
with a reduction in the number of sex exchange partners
(Sherman 2010)
• The addition of manager training to peer education was
found to increase the likelihood of HIV testing among FSWs in
the Philippines (Chiao 2009)
It is not possible to conclude definitively that no positive effect has
been achieved by some interventions, either due to small sample
size or failure in the design of the studies, or both. This clearly
highlights of the need to clarify these issues for policy-makers and
researchers considering affordable options for improving the qual-
ity of interventions to reduce the transmission of HIV in resource-
limited settings. It also indicates the importance of good study
design when implementing behavioral intervention programs of
previously unknown quality.
This review was limited to examining the available literature
on female sex workers. Given their high mobility and high risk
of HIV exposure, male and transgender sex workers and their
clients should also be taken into account when considering the
spread of STIs. In spite of limited data, a number of non-RCTs
have determined the effect of HIV/AIDS behavioral interven-
tions in preventing HIV/STIs among targeted male sex work-
ers (Maticka-Tyndale 1997 in Thailand), male transgender sex
27Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
workers (Khan 2008 in Pakistan), and male clients of sex workers
(Leonard 2000 in Senegal, Barrington 2009 in Dominican Re-
public, and Hoque 2009 in Bangladesh), however, this systematic
review did not include non-RCTs, so these studies and the evi-
dence from them were not available to support the results in this
review.
Although some trials provided only minimal details of follow-up
length, the length or intensity of the interventions varied across
trials. It is important to note that follow-up assessments over six
months might have seen a reduction in the incidence rates of STIs
in Thailand, Madagascar and Mexico (Fontanet 1998, Feldblum
2005, Patterson 2008) and STI prevalence in China (Li 2006),
and in the number of sex exchange partners in India (Sherman
2010) compared with shorter or longer follow-up assessments.
Conversely, the results from the current review of consistent con-
dom use did not depend on the duration of the follow-up period.
For example, results from an RCT in Thailand (Fontanet 1998)
showed effective use of female condoms after a 6-month follow up
period and after a 24-month follow up period, but the intervention
failed to increase male condom use after a 24-month assessment
period, which means this phenomenon was not specific enough
to measure the reduction of HIV/STI incidence and prevalence.
This indicates that effective behavioral change interventions to in-
crease condom usage may be long-lasting and sustainable, which is
an important consideration in dealing with hard-to-reach, hidden
and mobile populations such as sex workers.
Despite its limitations, our review provides scientific evidence to
support social cognitive theory intervention and the promotion of
male and female condom use in order to reduce the transmission
of HIV/STIs in vulnerable populations, especially FSWs, when
compared with other behavioral approaches or no interventions.
This meta-analysis also could inform the design and implemen-
tation of future studies, especially in terms of the choice of tar-
get population, setting, intensity of assessment, and the content
of the intervention, and the findings of the studies included in
this review, as well as the methods that were successful, should
be considered by policy-makers, health workers and researchers in
designing new interventions for these communities.
Overall completeness and applicability of evidence
A total of 13 trials were selected for review. However, the available
data are limited for some outcomes and the results should thus
be interpreted with caution. Although the data is available, it is
not clear how easy it would be to apply the interventions to other
settings, or to generalize the findings to other population groups.
Studies identifying the effects of behavioral interventions on HIV
prevalence were not considered in this review although this out-
come is undoubtedly important in the reduction of HIV trans-
mission among sex workers. The interventions for all sex work-
ers were reviewed but only FSW programs were eligible based on
randomised methods. Male and transgender sex workers and their
clients were not included in the review due to the unavailability
of data and due to these factors the results of the meta-analyses
can only be applied to FSWs. Also, there was heterogeneity in the
intervention effects for many of the outcomes, and there is no in-
formation as to the specific factors that might have caused the dif-
ferences between the intervention and control groups. However,
with regard to our objective, the findings of the review indicate
that the use of social cognitive-based theory and the promotion of
female and male condom use as HIV behavioral prevention strate-
gies play an important role in reducing HIV/STI incidence, along
with increasing condom use consistently and reducing illegal drug
use risk behavior among FSWs in low- and middle-income coun-
tries. Because these interventions are likely to be low-cost, capable
of being implemented by relatively unskilled workers, and can be
easily maintained over long periods, they provide an important
tool for controlling the spread of HIV amongst high-risk groups
in low- and middle-income countries.
Quality of the evidence
The quality of the evidence has been assessed using the GRADE
process (Guyatt 2008), and the results are presented in the
Summary of findings for the main comparison, Summary of
findings 2, Summary of findings 3, and Summary of findings 4.
The GRADE approach uses four levels of quality (very low, low,
moderate and high) over several domains covering limitations in
the design and implementation of studies, indirectness of evidence,
unexplained heterogeneity or inconsistency in results, imprecision
of results and high probability of publication bias. The highest
quality rating was found in six trials (Fontanet 1998, Ray 2001,
Hoke 2007, Patterson 2008, Chiao 2009, Sherman 2010). The
assessment of the risk of bias in these trials suggests concern re-
garding insufficient information of sequence generation, alloca-
tion concealment and failure to adequately address incomplete
outcome data. Methodological quality was rated as ”high“ for only
four of the thirteen trials (Fontanet 1998, Ray 2001, Patterson
2006, Sherman 2010), .
Potential biases in the review process
All authors have an interest in HIV behavior prevention interven-
tions, and each brings a different perspective to the methods used.
However, we made efforts to limit the bias in several ways: two
review authors assessed eligibility for inclusion and assessed the
risk of bias independently. Although the authors’ views varied, af-
ter extensive discussion and achieving a consensus, we decided to
accept the final conclusions. We knew that a meta-analysis might
be vulnerable to publication bias in the review process. However,
we were not able to use funnel plots due to the heterogeneity of
the study designs. But we did try to ensure that our eventual con-
clusion arose solely from the data. Feedback from readers interna-
tionally will serve to improve the next review update.
Agreements and disagreements with other studies or reviews
28Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
These results indicate that combined HIV behavioral prevention
strategies have a greater potential for positive results than single
interventions such as peer education or manager training alone
(Chiao 2009). These results are consistent with those from cluster
non-RCTs that tested the combined effects of educational inter-
ventions and the promotion of condom use in reducing HIV and
STI incidence in India (Bhave 1995) and Indonesia (Ford 2002).
However, when a health education intervention was combined
with the promotion of condoms, it resulted in the intervention
having either no effect or in an increase in condom use among
FSWs in Nicaragua (Egger 2000). The effectiveness of these in-
terventions, moreover, may not be assumed when the objective is,
for example, to improve the knowledge of HIV/STI, or to change
self-reported or observed behavior, such as sexual risk behavior
and the frequency of sexual encounters. Our systematic review in
low- and middle income countries shows that not all behavioral
interventions have a positive impact when it comes to preventing
HIV/STI infections or other secondary outcomes. This finding
is consistent with the systematic review of interventions for sex
workers in high-income countries, in which the effect of behav-
ioral interventions did not significantly reduce the STI incidence
and increase the use of condoms (Ota 2011).
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
HIV transmission among sex workers and their clients helps
to drive a broader epidemic of heterosexually-acquired HIV
(UNAIDS 2009), resulting in transmission even among individ-
uals who engage in low levels of risk behavior. Interventions to re-
duce the risk of HIV transmission amongst these high-risk groups
are therefore an important part of the international response to
the HIV epidemic, and should be assessed carefully for their suit-
ability, cost and effectiveness. This review strongly considers the
effectiveness of several ongoing behavioral interventions that are
likely to be available to policy makers and healthcare workers in
low- and middle-income nations. Policy makers, practitioners and
researchers therefore have a greater range of choice of potential
interventions to reduce HIV transmission risk among high-risk
groups. Before making a practice decision based on the current re-
view, further information from other reviews considering how the
role of combining sexual risk reduction, condom promotion and
improved access to STI treatment reduces HIV and STI acqui-
sition in sex workers receiving these interventions (Shahmanesh
2008) should to be taken into account. Nevertheless, given the
observed effectiveness of social cognitive theory and the promo-
tion of condom use in reducing transmission of HIV/STIs, and
the clear need for a reduction in transmission, these behavioral in-
terventions should be considered for implementation in high-risk
FSW communities in low- and middle-income countries. This
decision should be supported, however, by the knowledge that
there is lack of information about most other outcomes and target
populations, and although there is evidence in favour of their im-
plementation amongst other high-risk populations (such as trans-
gender sex workers) the quality of this evidence is not currently
sufficient to conclude that they will be effective amongst these
populations. The studies reviewed here did not cover the full range
of developing nations, but were spread across three continents and
so be sufficient to inform policy-makers from nations not repre-
sented in the current review. This review finds that the effects of
some interventions were sustained in radically different national
and local settings, indicating that the interventions be suitable in
most low- and middle-income countries.
Implications for research
Researchers designing new RCTs in to measure intervention effects
should strongly consider measuring HIV incidence and prevalence
as outcomes, and assess risk-factors for the spread of this infec-
tion. More high quality RCTs are urgently needed to further clar-
ify which behavioral interventions are most effective in reducing
the transmission of HIV among high-risk, hidden or marginalized
populations in low- and middle-income countries. Moreover, be-
cause sub-Saharan Africa remains the most heavily affected region
of heterosexual transmission, including among sex workers, critical
evaluation of interventions there should be conducted. Further-
more, the cost-effectiveness of these interventions, particularly so-
cial cognitive behavioral interventions and the promotion of con-
dom use as effective strategies targeted at vulnerable populations
should be a priority area for research. Therefore, detailed data on
the cost of interventions should be collected and analysed in a
standardized format, and future implementation programs should
consider enhanced study design and collection methods, to ensure
that key findings from those studies are valid, generalizable and of
high quality.
A C K N O W L E D G E M E N T S
We are grateful to Nagaraj Kondagunta, Sreekumaran Nair, Vinod
Bhat, Debashis Dutt, and Nalini Sathiakumar who developed the
original protocol. We are also grateful to Stuart Gilmor and An-
drew Stickley for their comments and suggestions on the draft of
the review.
29Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
R E F E R E N C E S
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35Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Basu 2004
Methods Design: Quasi-randomized controlled trial
Random allocation: means of a random number table
Date: unclear (15 months)
Participants Number: Each community consisted 350 sex workers. 100 FSWs were randomly selected
in each area (n=200) using a two-stage randomisation process. 10 sex workers in each
area were over sampled at baseline to account for refusal and loss at the first follow-up
Inclusion criteria: FSWs those who live and work in selected communities and provided
informed consent
Setting: Community-based
Country: India
Interventions ”Community empowerment“ versus ”standard care“
Intervention: FSWs received basic STI information. Additionally, health clinics were
established in the centre of both communities’ red light areas to improve existing care
for sex workers. They also received training by a team of local peer educators to build
skills and confidence in providing education and to foster empowerment and advocacy
for local sex workers. The training comprised empowerment and advocacy, included
sustained engagement with local sex workers, showed interest in sex workers’ health and
well-being and that of their children, nurtured group solidarity among them, and raised
consciousness about sex worker rights
Control: FSWs did not receive the enhanced intervention to prevent HIV and STIs
Outcomes 1. Consistent condom utilization
2. Change in condom use
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”Communities were randomly assigned to
an intervention and control condition“
Allocation concealment (selection bias) Low risk ”First, the brothel rooms in each red-light.
...using a random number table“
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk The study did not address this
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition/exclu-
sions; no reasons for missing data provided
36Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Basu 2004 (Continued)
Selective reporting (reporting bias) Low risk The study protocol is available and the
study’s outcome have been reported
Other bias Low risk Baseline characteristics were comparable
Chiao 2009
Methods Design: Quasi-randomized trial
Random allocation: sequential random selection of study sites
Date: unclear
Participants Number: 980 FSWs at baseline and 903 at posttest FSWs.
Inclusion criteria: FSWs who were employed at establishment and who were self-reported
ever engaging in commercial sex
Exclusion criteria: FSWs who failed to provide key information about HIV testing and
condom use behavior
Setting: Establishment-based
Coutry: Philippines
Interventions Intervention: (1) peer education, (2) manager training, (3) a combination of peer edu-
cation and manager training
1) The peer education intervention was implemented in Legaspi. A 5-day training in-
cluded basic information on STIs and HIV, modes of transmission, interpersonal rela-
tionship with peers and clients in the work establishment, sexual negotiation, and role
playing/modelling was implemented to all participants
2) Manager training intervention was conducted in Cagayan de Oro, consisted of the
same topic as the peer education intervention, and training on the manager’s social
influence role was added
3) The combined intervention of peer education and manager training was implemented
to all participants in two contiguous cities in Cebu
Control: Usual care was conducted in Ilo-Ilo. Participants received standard treatment
which consisted of regular examinations at the health centers
Outcomes 1. HIV testing changes
2. Consistent condom use
3. HIV-related knowledge
4. AIDS perceived control
5. AIDS perceived severity
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”The research design was a simple ran-
domised quasi-experimental approach...“
37Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Chiao 2009 (Continued)
Allocation concealment (selection bias) Low risk ”...number for each of the four sites were
placed in a box....“
Blinding (performance bias and detection
bias)
All outcomes
High risk Either participants or some key study per-
sonnel were not blinded
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk ”24/1,004 (2%) missing data“ was reported
but reasons for missing data were not de-
scribed
Selective reporting (reporting bias) Low risk The study protocol is available and all of
the study’s outcome have been reported
Other bias Unclear risk ”The participant rates of FSWs at baseline
and posttest assessments were over 95%,
reducing the likelihood of a biased partici-
pant pool“ but Table 1 shows the baseline
and posttest were imbalance
Feldblum 2005
Methods Design: Randomized controlled trial
Random allocation: Computer-generated list stratified by study site was created by using
a block permuted approach with block size of 20, 10 and 4
Date: February to August 2001, and follow-up visits extended to June 2002
Participants Number: 1000 FSWs (500 FSWs at each site)
Inclusion criteria: 18 years or older, self identified active sex workers with no signs of
pregnancy
Setting: Dispensary-based
Country: Madagascar
Interventions ”Peer education plus clinic based counselling“ versus ”peer counselling only“
Intervention: FSWs received three bimonthly clinic counselling sessions. A 15-minute
counselling session involved a two way exchange of information on the following com-
ponents: individual risk assessment; transmission and verification of basic knowledge
about STIs and HIV; dual protection; demonstration of condom use with opportunity
to practice using models; counselling tailored to individual circumstances; reinforcement
of skill for negotiating condom use; and promotion of the ”no condom = no sex“ policy
Control: FSWs received condom promotion and risk reduction counselling delivered by
peer educators
Outcomes 1. STI prevalence
2. Consistent male/female or male and female condom use
Notes
38Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Feldblum 2005 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”Participants were individually randomised
to receive condom counselling....“
Allocation concealment (selection bias) Low risk A computer generated random allocation
list stratified by study site was created at
FHI using a block permuted approach with
block sizes of 20, 10 and 4
Blinding (performance bias and detection
bias)
All outcomes
Low risk ”....STI testing and reporting were done by
laboratory staff blinded to group assign-
ment“
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk No reasons for missing data provided
Selective reporting (reporting bias) Low risk The study protocol is available and all the
study’s outcome have been reported
Other bias Low risk The intervention and control groups are
balance
Fontanet 1998
Methods Design: Randomized controlled trial
Random allocation: numbered table
Date: October 1994 to January 1995
Participants Number: 504 FSWs working at 71 sex establishments
Inclusion criteria: Women were at least 18 years of age, were not using a diaphragm,
a cervical cap nor vaginal spermicides, had no evidence of intravenous drug use, were
willing to use the condoms as instructed, and were willing to keep a pictorial coital log
recording all sexual acts with clients and non-commercial sexual partners
Setting: Sex establishments
Country: Thailand
Interventions ”Promotion of female and male condom use“ and ”promotion of male condom use“
Intervention: FSWs proposed a male condom to their clients as a first choice, but have the
option of using a female condom when clients refused or could not use a male condom
Control: FSWs proposed a male condom to their clients, and, if clients refused or could
not use male condoms, they were instructed not to have sex
Outcomes 1. STIs incidence
2. Consistent condom use
39Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Fontanet 1998 (Continued)
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”The randomisation was into two groups..
..“
Allocation concealment (selection bias) Low risk ”The randomisation procedure relied on a
table of random numbers matched with the
list of sex establishments, and took into ac-
count...“
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk The study did not address this.
Incomplete outcome data (attrition bias)
All outcomes
Low risk 4.3% (11) in female/male group and 11.
7% (33) in male condom group were loss
to follow up, but no statistically significant
differences on the baseline characteristics
of the FSWs without follow-up in the two
trial groups
Selective reporting (reporting bias) Low risk Study procedure and all study’s outcome
have been reported
Other bias Low risk Intervention and control groups compara-
ble at baseline are balance
Ghys 2001
Methods Design: Randomized controlled trial
Random allocation: unclear
Date: June 1994 to November 1997
Participants Number: 542 FSWs
Inclusion criteria: HIV negative or HIV-2 seropositive when tested in the first the screen-
ing
Setting: HIV/STD clinic
Country: Cote d’Ivoire
Interventions ”Intensive STI screening“ versus ”basic STI screening“
Intervention: FSWs randomised to the intensive STI screening and treatment strategy
were examined every month, regardless of the presence of symptoms
Control: FSWs randomised to the basic STI screening and treatment strategy were
examined only if they reported following symptoms: vaginal discharge, lower abdominal
40Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Ghys 2001 (Continued)
pain or a genital ulcer
Outcomes 1. HIV incidence
2. STI prevalence
3. Consistent condom use
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”....women were randomised to either an
intensive or a basic STI screening and treat-
ment strategy“
Allocation concealment (selection bias) Unclear risk The study did not address this
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk The study did not address this
Incomplete outcome data (attrition bias)
All outcomes
Low risk Reason for missing outcome data unlikely
to be related to true outcome
Selective reporting (reporting bias) Low risk The study protocol is available and all the
study’s outcome have been reported
Other bias Low risk The intervention and control groups com-
parable at baseline are balance
Gutierrez 2010
Methods Design: Cluster-randomized controlled trial
Random allocation: unclear
Date: Between 2003/2004 and 2007
Participants Number: 3,442 FSws and 2,786 MSM; we excluded MSM data.
Setting: Community-based.
Country: India.
Interventions ”Community empowerment“ versus ”standard care“
Intervention: The community-based (Frontiers Prevention Project) set out to empower
target populations by improving advocacy within these groups, and increasing commu-
nity awareness, by combining the provision of a comprehensive package of prevention
interventions implemented on the appropriate scale
Control: Participants in the control group received intervention but not intensive
41Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gutierrez 2010 (Continued)
Outcomes 1. STIs prevalence
2. Consistent condom use
3. HIV knowledge
4. HIV testing
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk 24 geographically distinct sites randomised
as either FPP or no FPP
Allocation concealment (selection bias) Unclear risk The study did not address this.
Blinding (performance bias and detection
bias)
All outcomes
High risk No blinding
Incomplete outcome data (attrition bias)
All outcomes
High risk The study did not address the missing data
Selective reporting (reporting bias) Unclear risk The study protocol was described, but not
all the outcomes were reported
Other bias Low risk Intervention and control groups are bal-
ance
Hoke 2007
Methods Design: Randomised controlled trial
Random allocation: Computer-generated list stratified by study site was created by using
a block permuted approach with block size of 20, 10 and 4
Date: unclear
Participants Number: 901 FSWs
Inclusion criteria: FSWs who completed the 6-month visit of the trial’s first phase
Setting: Public dispensaries
Country: Madagascar
Interventions ”Peer education plus clinic-based counselling“ versus ”peer education alone“
Intervention: Participants randomly assigned to the peer+clinic arm additionally received
bi-monthly clinic counseling sessions. The counseling sessions involved two-way ex-
change of information concerning individual risk assessment; transmission and verifica-
tion of basic knowledge about STI/HIV; dual protection, demonstration of use of both
types of condoms with opportunity to practice using model, reinforcement of skills for
negotiating condom use, and promotion of the ”no condom=no sex“ policy
42Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hoke 2007 (Continued)
Control: Did not receive the sessions as intensive as intervention group
Outcomes 1. STIs prevalence
2. Consistent condom use
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk The 901 participants who completed the
6-month visit of the trial’s first phase were
randomised again to receive in Phase 2 ei-
ther prevention counselling by peer educa-
tors or peer counselling plus clinic-based
counselling
Allocation concealment (selection bias) Low risk Group assignment was guided by a com-
puter-generated random allocation list
stratified by study site created at FHI us-
ing a block permuted approach with block
sizes of 20, 10 and 4
Blinding (performance bias and detection
bias)
All outcomes
Low risk Clinic staff and participants were not
blinded to group assignment, but labora-
tory staff were blinded
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Peer-only promotion group: 19 FSWs were
lost to follow up, and peer+clinic promo-
tion group: 26 FSWs were lost to follow up.
Reasons for missing data are not described
Selective reporting (reporting bias) Low risk The study protocol is available and all the
study’s outcome have been reported
Other bias Low risk The intervention and control groups are
balance
Li 2006
Methods Design: Quasi-randomized controlled trial
Random allocation: unclear
Date: unclear
Participants Number: 400 FSWs
Inclusion criteria: Women who worked in the establishments
Setting: Restaurants, barbershop and hair-washing rooms in suburban area
Country: China
43Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Li 2006 (Continued)
Interventions ”VCT intervention“ versus ”standard care of STIs“
Intervention: Two sessions of VCT were conducted; 1) a 25-minute pretest session before
STI screening to achieve risk reduction goals, 2) a 20-minute posttest session after STI
screening to discuss STI test result, and assess the study outcomes
Control: a-15 minute standard care, including messages about STI testing, treatment
and prevention
Outcomes 1. STIs prevalence
2. Consistent condom use
3. HIV/STIs knowledge
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Random selected samples were assigned to
either the intervention group or the control
group
Allocation concealment (selection bias) Unclear risk The study did not address this allocation
concealment
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk The study did not address this.
Incomplete outcome data (attrition bias)
All outcomes
Low risk 54 women were not enrolled in the trial
and 122 women were lost to follow up, but
reasons for missing outcome data unlikely
to be related to true outcome
Selective reporting (reporting bias) Low risk The study procedure is available and all
study’s outcome have been reported
Other bias High risk Demographic characteristics and baseline
outcome measures were significantly differ-
ent
44Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Markosyan 2010
Methods Design: Randomised controlled trial
Random allocation: Flip of a coin
Date: Between August 2007 and July 2008
Participants Number: 120 FSWs; 54 in intervention group and 66 in control group
Inclusion criteria: Female, 18 years of age or older, trading sex for money in the past 7
days, and written informed consent
Setting: Snowball and street-based outreach
Country: Armenia
Interventions ”Social cognitive theory“ versus ”no intervention“
Intervention: FSWs were asked to complete the questionnaires including the Informa-
tion-Motivation-Behavioural Skills Model, the Health Belief Model, and the theory of
Gender and Power. 2-hour intervention emphasized empowerment, self-efficacy to per-
suade clients to use condoms, and condom application skills implemented by health
educator
Control: FSWs did not receive any intervention but were scheduled for their follow-up
appointment and were free to leave the study site
Outcomes 1. Consistent condom use
2. HIV knowledge
3. Psychosocial barriers to condom use
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk FSWs were randomly assigned to either the
HIV prevention or a wait-list control con-
dition through the flip of coin
Allocation concealment (selection bias) Low risk ”...through the flip of coin“
Blinding (performance bias and detection
bias)
All outcomes
Low risk At baseline, 3- and 6-month follow-up, the
interviewer remained blind to participant’s
group assignment
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk The study did not address this outcome
Selective reporting (reporting bias) Low risk All outcomes reported
Other bias Low risk Randomization has essentially balanced the
characteristics of the intervention and con-
trol groups
45Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Patterson 2006
Methods Design: Randomized controlled trial
Random allocation: computer generated
Date: Between January 2004 and January 2006
Participants Number: 270 FSWs, 137 of whom were randomised to the intervention (denoted SSS)
and 133 to the comparison condition (CDC). An additional 342 women were recruited
in Ciudad Juarez and randomised to either SSS (N=172) or CDC (N=170)
Inclusion criteria: Self-identified as sex workers, at least 18 years old, reported had un-
protected vaginal, oral or anal sex with a client at least once in the previous month
Exclusion criteria: consistent condom use or dental dam for vaginal, oral and anal sex
with clients in the previous month, employed as a FSWs for less than one month, and
under 18 years of age
Setting: Venue- and street-based outreach. The interventions were carried out at a com-
munity-based clinic, mobile-clinic, private clinic and a government-operated Municipal
Medical Clinic
Country: Mexico
Interventions ”Social cognitive theory“ versus ”standard care“
Intervention: FSWs were interviewed face-to-face, to complete and covered a range of
topic including sexual risk behavior, working conditions, financial need, victimization
and trauma, use of alcohol and illicit drugs, social support, social influence, life expe-
riences, mood, self-esteem, social cognitive theory, social-demographic characteristics,
physical health variables, and psychiatric health variables
Control: 30 to 40 minutes face-to-face standard counselling focused on personal risk
assessment, cultural identity assessment, and strategies for reducing personal risk
Outcomes 1. Consistent condom use
2. Sexual activity outcomes
3. Drug use
4. Alcohol use
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”....participants were randomly assigned to
either Proyecto Comparte Sexo Mas Seguro
or time-equivalent voluntary HIV coun-
selling and testing“
Allocation concealment (selection bias) Low risk ”....using a fixed, computer generated ran-
domisation scheme“
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk No information
46Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Patterson 2006 (Continued)
Incomplete outcome data (attrition bias)
All outcomes
Low risk No missing data
Selective reporting (reporting bias) Low risk All outcome have been reported
Other bias Low risk There were no differences between the in-
tervention and comparison conditions
Patterson 2008
Methods Design: Randomized controlled trial
Random allocation: Computer-generated randomisation scheme.
Date: Between January 2004 and January 2006.
Participants Number: 924 FSWs (474 in Tijuana and 450 in Ciudad Juarez)
Inclusion criteria: 18 years old or older, giving informed consent, and having traded sex
for drugs, money or other material benefit within the previous two months and were
also required to have had unprotected vaginal sex with at least a client in the previous
two months
Exclusion criteria: FSWs those who reported had previously tested HIV positive
Setting: Venue- and street-based.
Country: Mexico
Interventions ”Social cognitive theory“ versus ”standard counselling“
Intervention: Motivational interviewing techniques to elicit information on the partic-
ipants’ current situation and motivations, and to increase their motivation to practice
safer sex. Four main areas were addressed: 1) motivations for practicing safer sex versus
those for practicing unsafe sex; 2) barriers to condom use; 3) techniques for negotiating
safer sex with clients; 4) enhancement of social supports
Control: A face-to face, time equivalent didactic presentation of prevention materials
extracted from the US Centers for Disease Control and Prevention revised guidelines
for HIV counselling, testing, and referral and from Mexico’s National Center for AIDS
Studies. Counseling session was focus on personal risk assessment, cultural identity
assessment, and strategies for reducing personal risk
Outcomes 1. HIV incidence
2. STIs incidence
3. Consistent condom use
4. Sexual activity outcomes
5. Injected drug use
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
47Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Patterson 2008 (Continued)
Random sequence generation (selection
bias)
Low risk ”We randomised the participants to either
the intervention using a fixed, computer-
generated randomization scheme“
Allocation concealment (selection bias) Low risk ”......computer-generated randomisation
scheme“
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk The study did not address this.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk No reasons for missing data provided
Selective reporting (reporting bias) Low risk The study protocol is available and all of
the study’s pre-specified outcomes that are
of interest in the review have been reported
Other bias Low risk Baseline characteristics are balance
Ray 2001
Methods Design: Randomized controlled trial
Random allocation: Numbered sealed envelopes
Date: unclear
Participants Number: 149 FSWs
Inclusion criteria: were residents of Harare, over 18 years old, had at least three different
paying clients in the previous month, written informed consent
Setting: Brothels
Country: Zimbabwe
Interventions ”Promotion of female and male condom use“ versus ”promotion of male condom use
alone“
Intervention: FSWs received a 30-minute education sessions on how to use female and
male condoms, and asked to practice how to use that. Additionally, a 10-hour focus
group discussion were held with 3-4 FSWs per group
Control: FSWs were shown how to use male condoms.
Outcomes 1. HIV incidence
2. STIs incidence
3. Consistent condom
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
48Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Ray 2001 (Continued)
Random sequence generation (selection
bias)
Low risk ”....were used to assign women to group A
or B randomly“
Allocation concealment (selection bias) Low risk ”Consecutively numbered sealed envelopes
containing group assignments (generated
by random number tables and balanced in
blocks of 10)....“
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk The study did not address this .
Incomplete outcome data (attrition bias)
All outcomes
Low risk Only 48% completed five follow-up visits,
but there were no differences in follow-up
rates between group A and group B
Selective reporting (reporting bias) Low risk Study procedures and frequency of follow-
up were identical for both study groups. All
study’s outcome have been reported
Other bias Low risk There were no differences in baseline de-
mographic
Sherman 2010
Methods Design: Randomized controlled trial
Random allocation: by random sequences of block sizes of 24 participants
Date: Between August and September 2008
Participants Number: 128 FSWs were screened for study eligibility; 104 (81%) were eligible for
randomization
Inclusion criteria: aged over 18, reported having participated in transactional sex over
the past 12 months, and able to provide written informed consent
Exclusion criteria: FSWs who participated in an HIV prevention program or a study in
the prior 12 months
Setting: Street-based
Country: India
Interventions ”Microenterprise plus education“ versus ”education alone“
Intervention: 8 hours of HIV prevention education taught by health educators plus 100
hours of tailoring training taught by master tailors. The training occurred over the course
of a month
Control: 8 hours prevention training (the same curriculum as the intervention arm) and
delivered by the same facilitator
Outcomes 1. Consistent condom use
2. Number of sex partners
49Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sherman 2010 (Continued)
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”The randomised trial was...“
Allocation concealment (selection bias) Low risk ”...participants were given an opaque,
sealed envelope containing computer-gen-
erated random assignments, prepared by
the study’s statistical team prior to the
beginning of recruitment. Randomization
was blocked with random sequences of
block sizes of 24 participants to ensure bal-
ance of 8-12 between the two arms“
Blinding (performance bias and detection
bias)
All outcomes
Low risk ”Interviewers were blind to the partici-
pants’ study arm“
Incomplete outcome data (attrition bias)
All outcomes
Low risk In the 6-month follow-up visit, control arm
participants were 48 (96%)
Selective reporting (reporting bias) Unclear risk Drug/alcohol outcomes have not been re-
ported
Other bias Low risk The intervention and control groups are
comparable at baseline
Swendeman 2009
Methods Design: Quasi-randomized controlled trial
Random allocation: random number table
Date: 2000-2001
Participants Number: 216 FSWs
Inclusion criteria: FSWs those who live and work in selected communities and provided
informed consent
Setting: Community-based
Country: India
Interventions ”Empowerment intervention (Sonagachi project)“ versus ”standard care“
Outcomes 1) HIV knowledge
2) Skills of risk and protective factors
50Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Swendeman 2009 (Continued)
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Participants were randomly assigned to an
intervention and control condition
Allocation concealment (selection bias) Low risk Allocation using a random number table
Blinding (performance bias and detection
bias)
All outcomes
Unclear risk The study did not address this outcome
Incomplete outcome data (attrition bias)
All outcomes
High risk The missing data was likely related to out-
comes
Selective reporting (reporting bias) Low risk The study protocol is available and the
study’s outcome have bee reported
Other bias Low risk “Since this loss to follow-up was likely re-
lated to outcomes, it would not violate the
less stringent missing at random (MAR)
requirement for unbiased estimates in re-
peated-measure analysis”
Wechsberg 2006
Methods Design: Randomized controlled trial
Random allocation: unclear
Date: unclear
Participants Number: 93 FSWs
Inclusion criteria: self-identified as a Black South African women, 18 years old or older,
either had a positive urine test for cocaine or reported recent substance use and sex
trading, had multiple partners and were provided written informed consent
Setting: Hotels, apartments, and informal settlements.
Country: South Africa
Interventions ”Social cognitive theory“ versus ”standard counselling“
Intervention: The intervention was based on principles of social cognitive theory, gender
theory, and empowerment. In additional, HIV-related education was tailored, and a risk
reduction and toiletry kit were given
Control: An adapted version of the revised NIDA standard intervention, which consisted
of two private one-hour education and skills building sessions
51Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wechsberg 2006 (Continued)
Outcomes 1. Consistent condom use
2. Drug use
3. Alcohol use
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk ”....were randomly assigned to a modified.
...“
Allocation concealment (selection bias) Unclear risk The study did not address.
Blinding (performance bias and detection
bias)
All outcomes
High risk Not blinding
Incomplete outcome data (attrition bias)
All outcomes
High risk The study did not address the missing data
(13 of 93)
Selective reporting (reporting bias) Low risk The study protocol is available and the
study’s outcome have bee reported
Other bias Unclear risk The is no information about the compari-
son of demographic characteristics between
intervention group and control group
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Abellanosa 1996 Pre-posttest study to examine the effectiveness of antibiotics to prevent STIs and HIV, but the participants
were not randomly assigned
Bakare 2002 Participants of this study were random selected of FSWs as an intervention group but the control group
was not FSWs
Barrington 2009 The study explored the relationship between social network norms and condom use among male partners
of FSWs in La Romana, Dominican Reprublic, but the participants were not randomly assigned to the
intervention and control groups
Beattie 2010 A baseline-follow up study examined if violence against FSWs is associated with reduced condom use and
increased STI/HIV risk by using polling booth surveys and integrated behavioral-biological assessment,
52Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
but the participants were not randomly assigned to these two interventions
Bhave 1995 A controlled intervention trial, with measurements before and after an HIV intervention underwent a 6-
month program of educational videos targeting sex workers and madams in the brothels of Bombay, but
the participants were not randomly assigned to the intervention and control groups
Dandona 2005 Not randomly assigned
Egger 2000 Not all of the participants were sex workers
Feldblum 2007 A randomised controlled trial to estimate the pregnancy incidence rate among Madagascar FSWs par-
ticipating in an intervention trial promoting use of male and female condoms and assess the influence
of various predictive factors on pregnancy risk. The data of this study was the secondary data collected
during a trial conducted in the previous study (Feldblum 2005)
Fonck 2000 This study was the baseline findings of a trial of antibiotic prophylaxis to prevent STIs and HIV-1 in a
cohort of Nairobi FSWs. The participants were not randomly assigned to peer education intervention
Ford 2002 This study assessed the impact of the educational intervention among FSWs in Bali, Indonesia. The
participants were divided by areas, high and low program effort to receive whether the health belief model
or the social cognitive theory
Gangopadhyay 2005 A comparative cross-sectional study of randomly selected FSWs in Calcutta, India compared rates of
STDs between the Sonagachi Project and National AIDS Control Organization (NACO) interventions,
but the participants were not randomly assigned
Gorbach 2000 This study quantified persons randomly selected from clusters of military, police, and motorcycle taxi
drivers in five cities of Cambodia, associations between behaviours, social context and active bridging
Guerena-Burgueno 1991 A pre-post test counselling assessed the prevalence of HIV-1 infection among high risk populations in
Tijuana, Mexico and information on risk behavior was obtained from 1,069 individuals
Hoque 2009 This study described behavioral profile of rickshaw pullers in Dhaka city and identified the correlates
for having sex with FSWs in order to focus HIV prevention intervention, but the participants were not
randomly assigned to receive the interventions
Kamali 2003 A community randomised trial which assessed the effect of behavioral intervention on incidence of HIV-
1, condom use and other STIs, but the participants not particularly FSWs
Kaul 2002 Baseline result of RCT study of treatment intervention
Kaul 2004 HIV treatment intervention
Kaul 2007 Placebo controlled trial of monthly oral azythromycin therapy (Azythromycin versus placebo), without
any additional behavior intervention
Kerrigan 2006 A pre-intervention post-intervention of two environmental-structural interventions of increases in con-
dom use with clients in reducing risks of HIV and STIs among FSWs in the Dominican Republic
53Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Khan 2008 This study assessed HIV behavioral intervention among male transgender, however the participants were
not randomly assigned
Larios 2009 This study examined the applicability of the Social Ecological Model for explaining condom use in a
sample of FSWs participating in a behavioral intervention to increase condom use in Tijuana, Mexico.
However, the participants were not randomly assigned to the intervention and control groups
Lau 2008 Behavioural surveillance study that investigated changes in HIV-related behaviours including condom
use and HIV-related knowledge among randomly selected FSWs, but the participants were not randomly
assigned to the intervention
Leonard 2000 Preintervention and postintervention study of a peer-led HIV prevention education and condom pro-
motion program among transport workers in Kaolack, Senegal
Maticka-Tyndale 1997 This study explored the social-cultural contexts and patterns of Thai men’s commercial sexual activity
including to use a condom
McClelland 2008 A randomised controlled study to test the efficacy of monthly periodic presumptive oral treatment with 2 g
of metronidazole plus 150 mg of flunocazole. Otherwise, this intervention did not include any behavioral
intervention
Ngugi 1988 A controlled clinical trial consisting a three arms in a situation where a true randomized controlled trial
would have been unethical. This study described the effect of an AIDS education program and the
distribution of free condoms and condom use among the prostitutes
Ngugi 1998 Baseline-follow up study that shown the effect of peer mediated intervention program among random
sample of FSWs to reduce STD and HIV transmission in Kenya and Zimbabwe
Ngugi 2007 Community-based post-trial resurvey of RCT among FSWs in Nairobi examined the sustainability of
such interventions
Nzila 1991 This study confirmed the HIV and STDs prevalence decreased by using condom, but the FSWs were
not randomly assigned to the intervention
Ramesh 2010 A probability-based sampling; conventional cluster sampling
Reza-Paul 2008 This study comprised two cross-sectional surveys, rather than an RCT
Rou 2007 Pre/post intervention trial set to evaluate the changes in condom use with the last three clients, and the
prevalence of chlamydia and gonorrhea
Schwandt 2006 A peer education intervention examined the practices of anal intercourse and dry sex within a cohort of
FSWs in Kenya, but the participants were not randomly assigned to the intervention and control groups
Strathdee 2009 The study used Social Cognitive Theory to determine whether increases in condom use were predicted
by social cognitive theory and injection drug user status among women randomised to this intervention
54Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Stulhofer 2009 The study compared and analysed the correlates of consistent condom use with clients among two clusters
FSWs in Croatia, but the participants were not randomly assigned
Walden 1999 The study measured the impact of peer educational and condom use among FSWs and truck drivers in
Malawi, but the participants were not randomly assigned to intervention and control groups
Weir 1998 An RCT used structured closed-ended questionnaires of estimating condom use, but cannot include
because there is no any follow-up data
Weir 1999 A randomized controlled study used structured closed-ended questionnaires of estimating condom use
without any follow-up
Yadav 2005 A cohort study examined the association of baseline social-demographic variables with the uptake and
durability of an HIV-1 behavioral risk reduction program in high-risk seronegative Kenyan FSW. This
study similar to Kaul 2004
Yi 2010 The study compared the risk factor and condom use among three groups of FSWs but subjects not
randomly assigned
55Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D A T A A N D A N A L Y S E S
Comparison 1. Social cognitive theory versus standard counseling for promotion of condom use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 HIV incidence among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2 STIs incidence among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
2.1 Syphilis incidence among
FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.2 Gonorrhoea incidence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.3 Chlamydia incidence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.4 Any STIs among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3 Consistent condom use by FSWs
at 6-month
2 804 Risk Ratio (M-H, Random, 95% CI) 1.14 [1.07, 1.21]
4 Mean number of condom use by
FSWs at past month
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
4.1 Vaginal sex using condoms
by FSWs with regular clients at
past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.2 Anal sex using condoms
by FSWs with regular clients at
past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.3 Oral sex using condoms
by FSWs with regular clients at
past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.4 Vaginal sex using condoms
by FSWs with non-regular
clients at past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.5 Anal sex using condoms
by FSWs with non-regular
clients at past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.6 Oral sex using condoms
by FSWs with non-regular
clients at past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.7 Vaginal sex using a
condom by FSWs with spouse
or steady partner
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.8 Anal sex using a condom
by FSWs with spouse or steady
partner at past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
56Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
4.9 Oral sex using a condom
by FSWs with spouse or steady
partner at past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
5 Mean number of protected sex
among FSWs at 6-month
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
6 Sexual activity outcomes by
FSWs at past month
2 Mean Difference (IV, Fixed, 95% CI) Totals not selected
6.1 Had vaginal sex at past
month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.2 Had anal sex at past
month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.3 Had vaginal and anal sex
at past month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.4 Had oral sex at past month 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
7 Injected drug use among FSWs
at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
8 Alcohol use among FSWs at
6-month
2 772 Risk Ratio (M-H, Random, 95% CI) 0.68 [0.46, 1.01]
9 Drug use among FSWs at
6-month
2 772 Risk Ratio (M-H, Random, 95% CI) 0.65 [0.36, 1.16]
Comparison 2. Social cognitive theory versus no intervention for promotion of condom use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Consistent condom use by FSWs 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
1.1 Consistent condom use by
FSWs with clients at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.2 Consistent condom use by
FSWs with clients in the past
7-day
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.3 Consistent application of
condom by FSWs
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2 HIV knowledge among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3 Psychosocial barriers to condom
use among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
3.1 Condom barriers among
FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3.2 Condom use self-efficacy
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
57Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 3. Community empowerment versus standard care for promotion of condom use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 STIs prevalence among FSWs at
36-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
1.1 Syphilis prevalence at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.2 HSV-2 prevalence at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2 Consistent condom use by FSWs
with regular partners
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3 Consistent condom use by FSWs
with clients
2 2330 Risk Ratio (M-H, Random, 95% CI) 1.08 [0.86, 1.36]
4 Change in 100% condom use by
FSWs
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
4.1 Change in condom use:
baseline to 6 months
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.2 Change in condom use:
baseline to 11 months
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.3 Change in condom use:
baseline to 16 months
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5 Change in any condom use by
FSWs
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
5.1 Change in condom use:
baseline to 6 months
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5.2 Change in condom use:
baseline to 11 months
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5.3 Change in condom use:
baseline to 16 months
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
6 HIV knowledge among FSWs 2 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
6.1 Knowledge that condom
could prevent STI (at
16-month)
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.2 Knowledge that condom
could prevent AIDS (at
16-month)
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.3 Knowledge about condom
(at 36-month)
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
7 HIV testing by FSWs at
36-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
8 Skills of risk and protective
factors among FSWs at
16-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
8.1 Know that she at risk for
STIs
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
8.2 Refused a client by FSWs
for a particular sex
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
58Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
8.3 Refused sex by FSWs with
a client who refused condom
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
Comparison 4. Microenterprise plus education intervention versus education alone for reducing the number of
sex partners
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Consistent condom use by FSWs
at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2 Number of FSWs’ partners at
6-month
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
2.1 Number of sex partners at
6-month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.2 Number of sex exchange
partners at 6-month
1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
Comparison 5. Peer education versus standard care for promoting HIV testing and condom use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of consistent
condom use by FSWs at
6-month
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2 Mean score of HIV knowledge
among FSWs at 6-month
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3 HIV testing by FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4 AIDS perceived control by
FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
4.1 To avoid AIDS
contraction
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.2 To control AIDS
contraction
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.3 To lower chance of getting
AIDS
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5 AIDS perceived severity by
FSWs at 6-month
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
5.1 Chance of getting AIDS 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
5.2 Worry about getting AIDS 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
59Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 6. Peer education plus clinic based counseling versus peer education only for promotion of condom
use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 STIs prevalence among FSWs 2 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
1.1 Chlamydia prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.2 Chlamydia prevalence
among FSWs at 12-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.3 Chlamydia prevalence
among FSWs at 18-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.4 Gonorrhoea prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.5 Gonorrhoea prevalence
among FSWs at 12-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.6 Gonorrhoea prevalence
among FSWs at 18-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.7 Trichomonas prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.8 Trichomonas prevalence
among FSWs at 12-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.9 Trichomonas prevalence
among FSWs at 18-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.10 Any STIs prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.11 Any STIs prevalence
among FSWs at 12-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.12 Any STIs prevalence
among at 18-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2 Male condom use with clients 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
2.1 Protected coital acts at
2-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.2 Protected coital acts at
4-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.3 Protected coital acts at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3 Male condom use with
non-paying partners
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
3.1 Male condom use in the
last coital act at 2-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3.2 Male condom use in the
last coital act at 4-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3.3 Male condom use in the
last coital act at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4 Female condom use by FSWs
with clients
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
4.1 Female condom use by
FSWs with clients at 12-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
60Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
4.2 Female condom use by
FSWs with clients at 18-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5 Male and female condom use
with clients
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
5.1 Male and female condom
use with clients at 12-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5.2 Male and female condom
use at 18-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
6 Male and female condom use in
the last sex with non-paying
partner
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
6.1 Male and female
condom use in the last sex
with non-paying partner at
12-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
6.2 Male and female
condom use in the last sex
with non-paying partner at
18-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
Comparison 7. Peer education plus manager training versus standard care for promoting HIV testing and condom
use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of consistent
condom use by FSWs at
6-month
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2 Mean score of HIV knowledge
among FSWs at 6-month
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3 HIV testing by FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4 AIDS perceived control by
FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
4.1 To avoid AIDS
contraction
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.2 To control AIDS
contraction
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.3 To lower chance of getting
AIDS
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5 AIDS perceived severity by
FSWs at 6-month
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
5.1 Chance of getting AIDS 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
5.2 Worry about getting AIDS 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
61Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 8. Manager training versus standard care for promoting HIV testing and condom use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of consistent
condom use by FSWs at
6-month
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2 Mean score of HIV knowledge
among FSWs at 6-month
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3 HIV testing by FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4 AIDS perceived control by
FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
4.1 Perception that condom
can avoid AIDS contraction
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.2 Perception that condom
can control AIDS contraction
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4.3 Perception that condom
can lower chance of getting
AIDS
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
5 Mean score of perceived
themselves at greater risk (by
FSWs at 6-month)
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
5.1 Chance of getting AIDS 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
5.2 Worry about getting AIDS 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
Comparison 9. Promotion of female and male condom versus promotion of male condom
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 HIV incidence among FSWs at
3-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2 STIs incidence among FSWs at
3-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
2.1 Trichomoniasis incidence
among FSWs at 3-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.2 Chlamydia incidence
among FSWs at 3-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.3 Gonorrhea incidence
among FSWs at 3-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3 Consistent male condom use at
3-months
2 572 Risk Ratio (M-H, Random, 95% CI) 0.83 [0.65, 1.05]
4 Consistent female condom use
by FSWs at 3-month
2 564 Risk Ratio (M-H, Random, 95% CI) 0.12 [0.09, 0.17]
5 Consistent female condom use
by FSWs at 24-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
62Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
6 Consistent male condom use at
24-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
Comparison 10. Intensive STI screening versus basic STI screening to control STI
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 HIV incidence among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
2 STIs prevalence among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
2.1 Trachomonas vaginalis
prevalence among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.2 Gonorrhoeae prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.3 Chlamydia trachomatis
prevalence among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3 Consistent condom use by FSWs
at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
Comparison 11. VCT versus standard care of STI for increasing condom use
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 STIs prevalence among FSWs at
6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
1.1 Syphilis prevalence among
FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.2 Gonorrhoea prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.3 Chlamydia prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.4 Trichomonas prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.5 Genital warts prevalence
among FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2 Consistent condom use by FSWs
with clients at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3 HIV/STI knowledge among
FSWs at 6-month
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
63Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.1. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 1 HIV incidence among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 1 HIV incidence among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Patterson 2008 0/341 4/368 0.12 [ 0.01, 2.22 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 0 (Experimental), 4 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 1.2. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 2 STIs incidence among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 2 STIs incidence among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Syphilis incidence among FSWs at 6-month
Patterson 2008 6/341 14/368 0.46 [ 0.18, 1.19 ]
2 Gonorrhoea incidence among FSWs at 6-month
Patterson 2008 9/341 14/368 0.69 [ 0.30, 1.58 ]
3 Chlamydia incidence among FSWs at 6-month
Patterson 2008 13/341 17/368 0.83 [ 0.41, 1.67 ]
4 Any STIs among FSWs at 6-month
Patterson 2008 20/341 38/368 0.57 [ 0.34, 0.96 ]
0.01 0.1 1 10 100
Favours experimental Favours control
64Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.3. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 3 Consistent condom use by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 3 Consistent condom use by FSWs at 6-month
Study or subgroup Favours experimental Control Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Patterson 2008 257/307 254/337 65.0 % 1.11 [ 1.03, 1.20 ]
Wechsberg 2006 78/80 66/80 35.0 % 1.18 [ 1.06, 1.32 ]
Total (95% CI) 387 417 100.0 % 1.14 [ 1.07, 1.21 ]
Total events: 335 (Favours experimental), 320 (Control)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.91, df = 1 (P = 0.34); I2 =0.0%
Test for overall effect: Z = 3.93 (P = 0.000086)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours experimental Favours control
65Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.4. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 4 Mean number of condom use by FSWs at past month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 4 Mean number of condom use by FSWs at past month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Vaginal sex using condoms by FSWs with regular clients at past month
Patterson 2006 309 11 (14) 303 9 (13) 2.00 [ -0.14, 4.14 ]
2 Anal sex using condoms by FSWs with regular clients at past month
Patterson 2006 309 0 (1) 303 0 (1) 0.0 [ -0.16, 0.16 ]
3 Oral sex using condoms by FSWs with regular clients at past month
Patterson 2006 309 4 (10) 303 3 (6) 1.00 [ -0.30, 2.30 ]
4 Vaginal sex using condoms by FSWs with non-regular clients at past month
Patterson 2006 309 38 (47) 303 34 (48) 4.00 [ -3.53, 11.53 ]
5 Anal sex using condoms by FSWs with non-regular clients at past month
Patterson 2006 309 0 (3) 303 0 (2) 0.0 [ -0.40, 0.40 ]
6 Oral sex using condoms by FSWs with non-regular clients at past month
Patterson 2006 309 12 (34) 303 8 (22) 4.00 [ -0.53, 8.53 ]
7 Vaginal sex using a condom by FSWs with spouse or steady partner
Patterson 2006 113 1 (3) 106 1 (2) 0.0 [ -0.67, 0.67 ]
8 Anal sex using a condom by FSWs with spouse or steady partner at past month
Patterson 2006 113 0 (1) 106 0 (1) 0.0 [ -0.27, 0.27 ]
9 Oral sex using a condom by FSWs with spouse or steady partner at past month
Patterson 2006 113 1 (4) 106 0 (1) 1.00 [ 0.24, 1.76 ]
-100 -50 0 50 100
Favours experimental Favours control
66Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.5. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 5 Mean number of protected sex among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 5 Mean number of protected sex among FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Patterson 2008 307 51.6 (49.1) 337 43.9 (49.1) 7.70 [ 0.11, 15.29 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable
-100 -50 0 50 100
Favours experimental Favours control
Analysis 1.6. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 6 Sexual activity outcomes by FSWs at past month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 6 Sexual activity outcomes by FSWs at past month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Had vaginal sex at past month
Patterson 2008 409 57 (59.8) 460 54.8 (55.2) 2.20 [ -5.48, 9.88 ]
2 Had anal sex at past month
Patterson 2008 409 8.4 (13.3) 460 9.6 (16.5) -1.20 [ -3.18, 0.78 ]
3 Had vaginal and anal sex at past month
Patterson 2008 409 58.6 (60.7) 460 56.8 (56.6) 1.80 [ -6.03, 9.63 ]
4 Had oral sex at past month
Patterson 2006 309 18 (42) 303 12 (30) 6.00 [ 0.23, 11.77 ]
-100 -50 0 50 100
Favours experimental Favours control
67Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.7. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 7 Injected drug use among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 7 Injected drug use among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Patterson 2008 66/409 88/460 0.84 [ 0.63, 1.13 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 66 (Experimental), 88 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 1.8. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 8 Alcohol use among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 8 Alcohol use among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Patterson 2006 34/309 47/303 88.8 % 0.71 [ 0.47, 1.07 ]
Wechsberg 2006 4/80 8/80 11.2 % 0.50 [ 0.16, 1.59 ]
Total (95% CI) 389 383 100.0 % 0.68 [ 0.46, 1.01 ]
Total events: 38 (Experimental), 55 (Control)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.31, df = 1 (P = 0.58); I2 =0.0%
Test for overall effect: Z = 1.93 (P = 0.053)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours experimental Favours control
68Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.9. Comparison 1 Social cognitive theory versus standard counseling for promotion of condom
use, Outcome 9 Drug use among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 1 Social cognitive theory versus standard counseling for promotion of condom use
Outcome: 9 Drug use among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Patterson 2006 10/309 22/303 37.6 % 0.45 [ 0.21, 0.93 ]
Wechsberg 2006 26/80 32/80 62.4 % 0.81 [ 0.54, 1.23 ]
Total (95% CI) 389 383 100.0 % 0.65 [ 0.36, 1.16 ]
Total events: 36 (Experimental), 54 (Control)
Heterogeneity: Tau2 = 0.10; Chi2 = 2.06, df = 1 (P = 0.15); I2 =52%
Test for overall effect: Z = 1.45 (P = 0.15)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 2.1. Comparison 2 Social cognitive theory versus no intervention for promotion of condom use,
Outcome 1 Consistent condom use by FSWs.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 2 Social cognitive theory versus no intervention for promotion of condom use
Outcome: 1 Consistent condom use by FSWs
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Consistent condom use by FSWs with clients at 6-month
Markosyan 2010 24/48 28/50 0.89 [ 0.61, 1.30 ]
2 Consistent condom use by FSWs with clients in the past 7-day
Markosyan 2010 29/48 33/50 0.92 [ 0.68, 1.24 ]
3 Consistent application of condom by FSWs
Markosyan 2010 5/48 8/50 0.65 [ 0.23, 1.85 ]
0.01 0.1 1 10 100
Favours experimental Favours control
69Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.2. Comparison 2 Social cognitive theory versus no intervention for promotion of condom use,
Outcome 2 HIV knowledge among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 2 Social cognitive theory versus no intervention for promotion of condom use
Outcome: 2 HIV knowledge among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Markosyan 2010 4/48 2/50 2.08 [ 0.40, 10.85 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 4 (Experimental), 2 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 2.3. Comparison 2 Social cognitive theory versus no intervention for promotion of condom use,
Outcome 3 Psychosocial barriers to condom use among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 2 Social cognitive theory versus no intervention for promotion of condom use
Outcome: 3 Psychosocial barriers to condom use among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Condom barriers among FSWs at 6-month
Markosyan 2010 8/48 10/50 0.83 [ 0.36, 1.93 ]
2 Condom use self-efficacy among FSWs at 6-month
Markosyan 2010 18/48 12/50 1.56 [ 0.85, 2.89 ]
0.01 0.1 1 10 100
Favours experimental Favours control
70Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.1. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 1 STIs prevalence among FSWs at 36-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 1 STIs prevalence among FSWs at 36-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Syphilis prevalence at 6-month
Gutierrez 2010 129/1292 68/855 1.26 [ 0.95, 1.66 ]
2 HSV-2 prevalence at 6-month
Gutierrez 2010 375/1292 180/855 1.38 [ 1.18, 1.61 ]
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 3.2. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 2 Consistent condom use by FSWs with regular partners.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 2 Consistent condom use by FSWs with regular partners
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Gutierrez 2010 180/855 491/1292 0.55 [ 0.48, 0.64 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 180 (Experimental), 491 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
71Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.3. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 3 Consistent condom use by FSWs with clients.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 3 Consistent condom use by FSWs with clients
Study or subgroup Experimental Control Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Basu 2004 67/90 58/93 40.8 % 1.19 [ 0.98, 1.46 ]
Gutierrez 2010 1279/1292 838/855 59.2 % 1.01 [ 1.00, 1.02 ]
Total (95% CI) 1382 948 100.0 % 1.08 [ 0.86, 1.36 ]
Total events: 1346 (Experimental), 896 (Control)
Heterogeneity: Tau2 = 0.02; Chi2 = 5.37, df = 1 (P = 0.02); I2 =81%
Test for overall effect: Z = 0.67 (P = 0.50)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 3.4. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 4 Change in 100% condom use by FSWs.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 4 Change in 100% condom use by FSWs
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Change in condom use: baseline to 6 months
Basu 2004 35/90 17/93 2.13 [ 1.29, 3.51 ]
2 Change in condom use: baseline to 11 months
Basu 2004 35/85 16/88 2.26 [ 1.36, 3.77 ]
3 Change in condom use: baseline to 16 months
Basu 2004 37/92 19/80 1.69 [ 1.06, 2.70 ]
0.01 0.1 1 10 100
Favours experimental Favours control
72Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.5. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 5 Change in any condom use by FSWs.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 5 Change in any condom use by FSWs
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Change in condom use: baseline to 6 months
Basu 2004 21/90 21/93 1.03 [ 0.61, 1.76 ]
2 Change in condom use: baseline to 11 months
Basu 2004 21/85 18/88 1.21 [ 0.69, 2.10 ]
3 Change in condom use: baseline to 16 months
Basu 2004 36/92 16/80 1.96 [ 1.18, 3.25 ]
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 3.6. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 6 HIV knowledge among FSWs.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 6 HIV knowledge among FSWs
Study or subgroup Favours experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Knowledge that condom could prevent STI (at 16-month)
Swendeman 2009 79/100 82/100 0.96 [ 0.84, 1.10 ]
2 Knowledge that condom could prevent AIDS (at 16-month)
Swendeman 2009 67/100 41/100 1.63 [ 1.24, 2.15 ]
3 Knowledge about condom (at 36-month)
Gutierrez 2010 116/1292 85/855 0.90 [ 0.69, 1.18 ]
0.01 0.1 1 10 100
Favours experimental Favours control
73Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.7. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 7 HIV testing by FSWs at 36-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 7 HIV testing by FSWs at 36-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Gutierrez 2010 1163/1292 744/855 1.03 [ 1.00, 1.07 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 1163 (Experimental), 744 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 3.8. Comparison 3 Community empowerment versus standard care for promotion of condom use,
Outcome 8 Skills of risk and protective factors among FSWs at 16-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 3 Community empowerment versus standard care for promotion of condom use
Outcome: 8 Skills of risk and protective factors among FSWs at 16-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Know that she at risk for STIs
Swendeman 2009 59/100 55/100 1.07 [ 0.84, 1.37 ]
2 Refused a client by FSWs for a particular sex
Swendeman 2009 62/100 53/100 1.17 [ 0.92, 1.49 ]
3 Refused sex by FSWs with a client who refused condom
Swendeman 2009 42/100 38/100 1.11 [ 0.79, 1.55 ]
0.01 0.1 1 10 100
Favours experimental Favours control
74Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 4.1. Comparison 4 Microenterprise plus education intervention versus education alone for
reducing the number of sex partners, Outcome 1 Consistent condom use by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 4 Microenterprise plus education intervention versus education alone for reducing the number of sex partners
Outcome: 1 Consistent condom use by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Sherman 2010 48/50 47/49 1.00 [ 0.92, 1.09 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 48 (Experimental), 47 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 4.2. Comparison 4 Microenterprise plus education intervention versus education alone for
reducing the number of sex partners, Outcome 2 Number of FSWs’ partners at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 4 Microenterprise plus education intervention versus education alone for reducing the number of sex partners
Outcome: 2 Number of FSWs’ partners at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Number of sex partners at 6-month
Sherman 2010 50 5 (5) 49 11.9 (10) -6.90 [ -10.02, -3.78 ]
2 Number of sex exchange partners at 6-month
Sherman 2010 50 3.1 (2) 49 5.1 (3) -2.00 [ -3.01, -0.99 ]
-100 -50 0 50 100
Favours experimental Favours control
75Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 5.1. Comparison 5 Peer education versus standard care for promoting HIV testing and condom
use, Outcome 1 Mean number of consistent condom use by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 5 Peer education versus standard care for promoting HIV testing and condom use
Outcome: 1 Mean number of consistent condom use by FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Chiao 2009 149 1.61 (1.24) 141 1.7 (0.97) -0.09 [ -0.35, 0.17 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable
-100 -50 0 50 100
Favours experimental Favours control
Analysis 5.2. Comparison 5 Peer education versus standard care for promoting HIV testing and condom
use, Outcome 2 Mean score of HIV knowledge among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 5 Peer education versus standard care for promoting HIV testing and condom use
Outcome: 2 Mean score of HIV knowledge among FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Chiao 2009 149 6.98 (1.3) 141 5.9 (1.43) 1.08 [ 0.76, 1.40 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable
-100 -50 0 50 100
Favours experimental Favours control
76Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 5.3. Comparison 5 Peer education versus standard care for promoting HIV testing and condom
use, Outcome 3 HIV testing by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 5 Peer education versus standard care for promoting HIV testing and condom use
Outcome: 3 HIV testing by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Chiao 2009 134/149 96/141 1.32 [ 1.17, 1.50 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 134 (Experimental), 96 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 5.4. Comparison 5 Peer education versus standard care for promoting HIV testing and condom
use, Outcome 4 AIDS perceived control by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 5 Peer education versus standard care for promoting HIV testing and condom use
Outcome: 4 AIDS perceived control by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 To avoid AIDS contraction
Chiao 2009 113/149 106/141 1.01 [ 0.88, 1.15 ]
2 To control AIDS contraction
Chiao 2009 117/149 119/141 0.93 [ 0.83, 1.04 ]
3 To lower chance of getting AIDS
Chiao 2009 59/149 75/141 0.74 [ 0.58, 0.96 ]
0.01 0.1 1 10 100
Favours experimental Favours control
77Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 5.5. Comparison 5 Peer education versus standard care for promoting HIV testing and condom
use, Outcome 5 AIDS perceived severity by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 5 Peer education versus standard care for promoting HIV testing and condom use
Outcome: 5 AIDS perceived severity by FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Chance of getting AIDS
Chiao 2009 149 1.76 (1.37) 141 3.23 (1.69) -1.47 [ -1.83, -1.11 ]
2 Worry about getting AIDS
Chiao 2009 149 2.83 (1.67) 141 3.85 (1.47) -1.02 [ -1.38, -0.66 ]
-100 -50 0 50 100
Favours experimental Favours control
Analysis 6.1. Comparison 6 Peer education plus clinic based counseling versus peer education only for
promotion of condom use, Outcome 1 STIs prevalence among FSWs.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 6 Peer education plus clinic based counseling versus peer education only for promotion of condom use
Outcome: 1 STIs prevalence among FSWs
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Chlamydia prevalence among FSWs at 6-month
Feldblum 2005 52/456 73/445 0.70 [ 0.50, 0.97 ]
2 Chlamydia prevalence among FSWs at 12-month
Hoke 2007 57/435 74/428 0.76 [ 0.55, 1.04 ]
3 Chlamydia prevalence among FSWs at 18-month
Hoke 2007 46/409 48/409 0.96 [ 0.66, 1.40 ]
4 Gonorrhoea prevalence among FSWs at 6-month
Feldblum 2005 73/456 91/445 0.78 [ 0.59, 1.03 ]
5 Gonorrhoea prevalence among FSWs at 12-month
0.01 0.1 1 10 100
Favours experimental Favours control
(Continued . . . )
78Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(. . . Continued)Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Hoke 2007 41/435 36/428 1.12 [ 0.73, 1.72 ]
6 Gonorrhoea prevalence among FSWs at 18-month
Hoke 2007 41/409 45/409 0.91 [ 0.61, 1.36 ]
7 Trichomonas prevalence among FSWs at 6-month
Feldblum 2005 69/456 79/445 0.85 [ 0.63, 1.15 ]
8 Trichomonas prevalence among FSWs at 12-month
Hoke 2007 120/435 126/428 0.94 [ 0.76, 1.16 ]
9 Trichomonas prevalence among FSWs at 18-month
Hoke 2007 130/409 108/409 1.20 [ 0.97, 1.49 ]
10 Any STIs prevalence among FSWs at 6-month
Feldblum 2005 144/456 181/445 0.78 [ 0.65, 0.93 ]
11 Any STIs prevalence among FSWs at 12-month
Hoke 2007 172/428 180/435 0.97 [ 0.83, 1.14 ]
12 Any STIs prevalence among at 18-month
Hoke 2007 166/409 156/409 1.06 [ 0.90, 1.26 ]
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 6.2. Comparison 6 Peer education plus clinic based counseling versus peer education only for
promotion of condom use, Outcome 2 Male condom use with clients.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 6 Peer education plus clinic based counseling versus peer education only for promotion of condom use
Outcome: 2 Male condom use with clients
Study or subgroup Favours experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Protected coital acts at 2-month
Feldblum 2005 358/480 364/483 0.99 [ 0.92, 1.06 ]
2 Protected coital acts at 4-month
Feldblum 2005 383/476 348/465 1.08 [ 1.00, 1.15 ]
3 Protected coital acts at 6-month
Feldblum 2005 370/447 334/435 1.08 [ 1.01, 1.15 ]
0.01 0.1 1 10 100
Favours experimental Favours control
79Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 6.3. Comparison 6 Peer education plus clinic based counseling versus peer education only for
promotion of condom use, Outcome 3 Male condom use with non-paying partners.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 6 Peer education plus clinic based counseling versus peer education only for promotion of condom use
Outcome: 3 Male condom use with non-paying partners
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Male condom use in the last coital act at 2-month
Feldblum 2005 79/243 80/268 1.09 [ 0.84, 1.41 ]
2 Male condom use in the last coital act at 4-month
Feldblum 2005 76/236 58/254 1.41 [ 1.05, 1.89 ]
3 Male condom use in the last coital act at 6-month
Feldblum 2005 70/258 58/264 1.23 [ 0.91, 1.67 ]
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 6.4. Comparison 6 Peer education plus clinic based counseling versus peer education only for
promotion of condom use, Outcome 4 Female condom use by FSWs with clients.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 6 Peer education plus clinic based counseling versus peer education only for promotion of condom use
Outcome: 4 Female condom use by FSWs with clients
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Female condom use by FSWs with clients at 12-month
Hoke 2007 278/435 291/428 0.94 [ 0.85, 1.03 ]
2 Female condom use by FSWs with clients at 18-month
Hoke 2007 235/409 252/409 0.93 [ 0.83, 1.04 ]
0.01 0.1 1 10 100
Favours experimental Favours control
80Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 6.5. Comparison 6 Peer education plus clinic based counseling versus peer education only for
promotion of condom use, Outcome 5 Male and female condom use with clients.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 6 Peer education plus clinic based counseling versus peer education only for promotion of condom use
Outcome: 5 Male and female condom use with clients
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Male and female condom use with clients at 12-month
Hoke 2007 370/435 344/428 1.06 [ 1.00, 1.13 ]
2 Male and female condom use at 18-month
Hoke 2007 360/409 350/409 1.03 [ 0.97, 1.09 ]
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 6.6. Comparison 6 Peer education plus clinic based counseling versus peer education only for
promotion of condom use, Outcome 6 Male and female condom use in the last sex with non-paying partner.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 6 Peer education plus clinic based counseling versus peer education only for promotion of condom use
Outcome: 6 Male and female condom use in the last sex with non-paying partner
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Male and female condom use in the last sex with non-paying partner at 12-month
Hoke 2007 124/435 94/428 1.30 [ 1.03, 1.64 ]
2 Male and female condom use in the last sex with non-paying partner at 18-month
Hoke 2007 119/409 86/409 1.38 [ 1.09, 1.76 ]
0.01 0.1 1 10 100
Favours experimental Favours control
81Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 7.1. Comparison 7 Peer education plus manager training versus standard care for promoting HIV
testing and condom use, Outcome 1 Mean number of consistent condom use by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 7 Peer education plus manager training versus standard care for promoting HIV testing and condom use
Outcome: 1 Mean number of consistent condom use by FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Chiao 2009 415 3.04 (1.87) 141 1.7 (0.97) 1.34 [ 1.10, 1.58 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable
-100 -50 0 50 100
Favours experimental Favours control
Analysis 7.2. Comparison 7 Peer education plus manager training versus standard care for promoting HIV
testing and condom use, Outcome 2 Mean score of HIV knowledge among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 7 Peer education plus manager training versus standard care for promoting HIV testing and condom use
Outcome: 2 Mean score of HIV knowledge among FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Chiao 2009 415 6.79 (1.39) 141 5.9 (1.43) 0.89 [ 0.62, 1.16 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable
-100 -50 0 50 100
Favours experimental Favours control
82Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 7.3. Comparison 7 Peer education plus manager training versus standard care for promoting HIV
testing and condom use, Outcome 3 HIV testing by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 7 Peer education plus manager training versus standard care for promoting HIV testing and condom use
Outcome: 3 HIV testing by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Chiao 2009 94/415 96/141 0.33 [ 0.27, 0.41 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 94 (Experimental), 96 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 7.4. Comparison 7 Peer education plus manager training versus standard care for promoting HIV
testing and condom use, Outcome 4 AIDS perceived control by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 7 Peer education plus manager training versus standard care for promoting HIV testing and condom use
Outcome: 4 AIDS perceived control by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 To avoid AIDS contraction
Chiao 2009 311/415 106/141 1.00 [ 0.89, 1.11 ]
2 To control AIDS contraction
Chiao 2009 292/415 119/141 0.83 [ 0.76, 0.92 ]
3 To lower chance of getting AIDS
Chiao 2009 367/415 75/141 1.66 [ 1.42, 1.95 ]
0.01 0.1 1 10 100
Favours experimental Favours control
83Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 7.5. Comparison 7 Peer education plus manager training versus standard care for promoting HIV
testing and condom use, Outcome 5 AIDS perceived severity by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 7 Peer education plus manager training versus standard care for promoting HIV testing and condom use
Outcome: 5 AIDS perceived severity by FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Chance of getting AIDS
Chiao 2009 415 2.38 (1.25) 141 3.23 (1.69) -0.85 [ -1.15, -0.55 ]
2 Worry about getting AIDS
Chiao 2009 415 3.35 (1.34) 141 3.85 (1.47) -0.50 [ -0.77, -0.23 ]
-100 -50 0 50 100
Favours experimental Favours control
Analysis 8.1. Comparison 8 Manager training versus standard care for promoting HIV testing and condom
use, Outcome 1 Mean number of consistent condom use by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 8 Manager training versus standard care for promoting HIV testing and condom use
Outcome: 1 Mean number of consistent condom use by FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Chiao 2009 198 1.79 (1.26) 141 1.7 (0.97) 0.09 [ -0.15, 0.33 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable
-100 -50 0 50 100
Favours experimental Favours control
84Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 8.2. Comparison 8 Manager training versus standard care for promoting HIV testing and condom
use, Outcome 2 Mean score of HIV knowledge among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 8 Manager training versus standard care for promoting HIV testing and condom use
Outcome: 2 Mean score of HIV knowledge among FSWs at 6-month
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Chiao 2009 198 6.31 (1.44) 141 5.9 (1.43) 0.41 [ 0.10, 0.72 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
Test for subgroup differences: Not applicable
-100 -50 0 50 100
Favours experimental Favours control
Analysis 8.3. Comparison 8 Manager training versus standard care for promoting HIV testing and condom
use, Outcome 3 HIV testing by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 8 Manager training versus standard care for promoting HIV testing and condom use
Outcome: 3 HIV testing by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Chiao 2009 191/198 96/141 1.42 [ 1.26, 1.59 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 191 (Experimental), 96 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
85Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 8.4. Comparison 8 Manager training versus standard care for promoting HIV testing and condom
use, Outcome 4 AIDS perceived control by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 8 Manager training versus standard care for promoting HIV testing and condom use
Outcome: 4 AIDS perceived control by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Perception that condom can avoid AIDS contraction
Chiao 2009 165/198 106/141 1.11 [ 0.99, 1.24 ]
2 Perception that condom can control AIDS contraction
Chiao 2009 177/198 119/141 1.06 [ 0.97, 1.15 ]
3 Perception that condom can lower chance of getting AIDS
Chiao 2009 124/198 75/141 1.18 [ 0.98, 1.42 ]
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 8.5. Comparison 8 Manager training versus standard care for promoting HIV testing and condom
use, Outcome 5 Mean score of perceived themselves at greater risk (by FSWs at 6-month).
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 8 Manager training versus standard care for promoting HIV testing and condom use
Outcome: 5 Mean score of perceived themselves at greater risk (by FSWs at 6-month)
Study or subgroup Experimental ControlMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Chance of getting AIDS
Chiao 2009 198 2.8 (1.72) 141 3.23 (1.69) -0.43 [ -0.80, -0.06 ]
2 Worry about getting AIDS
Chiao 2009 198 3.61 (1.62) 141 3.85 (1.47) -0.24 [ -0.57, 0.09 ]
-100 -50 0 50 100
Favours experimental Favours control
86Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.1. Comparison 9 Promotion of female and male condom versus promotion of male condom,
Outcome 1 HIV incidence among FSWs at 3-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 9 Promotion of female and male condom versus promotion of male condom
Outcome: 1 HIV incidence among FSWs at 3-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Ray 2001 0/99 3/50 0.07 [ 0.00, 1.38 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 0 (Experimental), 3 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 9.2. Comparison 9 Promotion of female and male condom versus promotion of male condom,
Outcome 2 STIs incidence among FSWs at 3-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 9 Promotion of female and male condom versus promotion of male condom
Outcome: 2 STIs incidence among FSWs at 3-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Trichomoniasis incidence among FSWs at 3-month
Fontanet 1998 11/249 8/255 1.41 [ 0.58, 3.44 ]
2 Chlamydia incidence among FSWs at 3-month
Fontanet 1998 50/249 72/255 0.71 [ 0.52, 0.98 ]
3 Gonorrhea incidence among FSWs at 3-month
Fontanet 1998 43/249 70/255 0.63 [ 0.45, 0.88 ]
0.01 0.1 1 10 100
Favours experimental Favours control
87Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.3. Comparison 9 Promotion of female and male condom versus promotion of male condom,
Outcome 3 Consistent male condom use at 3-months.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 9 Promotion of female and male condom versus promotion of male condom
Outcome: 3 Consistent male condom use at 3-months
Study or subgroup Experimental Control Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Fontanet 1998 219/249 250/255 66.6 % 0.90 [ 0.85, 0.94 ]
Ray 2001 25/42 22/26 33.4 % 0.70 [ 0.52, 0.95 ]
Total (95% CI) 291 281 100.0 % 0.83 [ 0.65, 1.05 ]
Total events: 244 (Experimental), 272 (Control)
Heterogeneity: Tau2 = 0.02; Chi2 = 2.86, df = 1 (P = 0.09); I2 =65%
Test for overall effect: Z = 1.54 (P = 0.12)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 9.4. Comparison 9 Promotion of female and male condom versus promotion of male condom,
Outcome 4 Consistent female condom use by FSWs at 3-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 9 Promotion of female and male condom versus promotion of male condom
Outcome: 4 Consistent female condom use by FSWs at 3-month
Study or subgroup Experimental Control Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Fontanet 1998 30/249 250/255 91.4 % 0.12 [ 0.09, 0.17 ]
Ray 2001 3/34 22/26 8.6 % 0.10 [ 0.03, 0.31 ]
Total (95% CI) 283 281 100.0 % 0.12 [ 0.09, 0.17 ]
Total events: 33 (Experimental), 272 (Control)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.08, df = 1 (P = 0.78); I2 =0.0%
Test for overall effect: Z = 12.88 (P < 0.00001)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours experimental Favours control
88Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.5. Comparison 9 Promotion of female and male condom versus promotion of male condom,
Outcome 5 Consistent female condom use by FSWs at 24-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 9 Promotion of female and male condom versus promotion of male condom
Outcome: 5 Consistent female condom use by FSWs at 24-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Fontanet 1998 10/68 57/60 0.15 [ 0.09, 0.28 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 10 (Experimental), 57 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 9.6. Comparison 9 Promotion of female and male condom versus promotion of male condom,
Outcome 6 Consistent male condom use at 24-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 9 Promotion of female and male condom versus promotion of male condom
Outcome: 6 Consistent male condom use at 24-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Fontanet 1998 59/68 57/60 0.91 [ 0.82, 1.02 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 59 (Experimental), 57 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
89Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 10.1. Comparison 10 Intensive STI screening versus basic STI screening to control STI, Outcome 1
HIV incidence among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 10 Intensive STI screening versus basic STI screening to control STI
Outcome: 1 HIV incidence among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Ghys 2001 6/108 10/117 0.65 [ 0.24, 1.73 ]
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 10.2. Comparison 10 Intensive STI screening versus basic STI screening to control STI, Outcome 2
STIs prevalence among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 10 Intensive STI screening versus basic STI screening to control STI
Outcome: 2 STIs prevalence among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Trachomonas vaginalis prevalence among FSWs at 6-month
Ghys 2001 29/273 26/269 1.10 [ 0.67, 1.82 ]
2 Gonorrhoeae prevalence among FSWs at 6-month
Ghys 2001 10/273 26/269 0.38 [ 0.19, 0.77 ]
3 Chlamydia trachomatis prevalence among FSWs at 6-month
Ghys 2001 3/273 13/269 0.23 [ 0.07, 0.79 ]
0.01 0.1 1 10 100
Favours experimental Favours control
90Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 10.3. Comparison 10 Intensive STI screening versus basic STI screening to control STI, Outcome 3
Consistent condom use by FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 10 Intensive STI screening versus basic STI screening to control STI
Outcome: 3 Consistent condom use by FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Ghys 2001 225/273 213/269 1.04 [ 0.96, 1.13 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 225 (Experimental), 213 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 11.1. Comparison 11 VCT versus standard care of STI for increasing condom use, Outcome 1 STIs
prevalence among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 11 VCT versus standard care of STI for increasing condom use
Outcome: 1 STIs prevalence among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Syphilis prevalence among FSWs at 6-month
Li 2006 8/141 15/137 0.52 [ 0.23, 1.18 ]
2 Gonorrhoea prevalence among FSWs at 6-month
Li 2006 12/141 14/137 0.83 [ 0.40, 1.74 ]
3 Chlamydia prevalence among FSWs at 6-month
Li 2006 20/141 29/137 0.67 [ 0.40, 1.13 ]
4 Trichomonas prevalence among FSWs at 6-month
Li 2006 8/141 15/137 0.52 [ 0.23, 1.18 ]
5 Genital warts prevalence among FSWs at 6-month
Li 2006 2/141 9/137 0.22 [ 0.05, 0.98 ]
0.01 0.1 1 10 100
Favours experimental Favours control
91Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 11.2. Comparison 11 VCT versus standard care of STI for increasing condom use, Outcome 2
Consistent condom use by FSWs with clients at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 11 VCT versus standard care of STI for increasing condom use
Outcome: 2 Consistent condom use by FSWs with clients at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Li 2006 74/141 35/137 2.05 [ 1.48, 2.85 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 74 (Experimental), 35 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
Analysis 11.3. Comparison 11 VCT versus standard care of STI for increasing condom use, Outcome 3
HIV/STI knowledge among FSWs at 6-month.
Review: Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries
Comparison: 11 VCT versus standard care of STI for increasing condom use
Outcome: 3 HIV/STI knowledge among FSWs at 6-month
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Li 2006 33/141 25/137 1.28 [ 0.81, 2.04 ]
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 33 (Experimental), 25 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.01 0.1 1 10 100
Favours experimental Favours control
92Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A P P E N D I C E S
Appendix 1. PUBMED SEARCH STRATEGY
Search Most Recent Queries Time Result
#44 Search #39 AND #40 AND #41 AND #
42 Limits: Publication Date from 1980/
01/01 to 2010/09/28
08:29:05 1005
#43 Search #39 AND #40 AND #41 AND
#42
08:27:24 1007
#42 Search intervention[tiab] OR interven-
tions[tiab] OR risk reduction behav-
ior[mh] OR risk reduction[tiab] OR
risk reducing[tiab] OR Health Knowl-
edge, Attitudes, Practice[mh] OR in-
cidence[mh] OR incidence[tiab] OR
prevalence[mh] OR prevalence[tiab]
OR sexual behavior[mh] OR sexual be-
havior[tiab] OR sexual behaviour[tiab]
OR intervention studies[mh]
08:27:05 1153751
#41 Search prostitute[tiab] OR prosti-
tutes[tiab] OR sex worker[tiab] OR sex
workers[tiab] OR prostitution[mh] OR
prostitution[tiab]
08:26:54 6708
#40 Search (randomized controlled trial [pt]
OR controlled clinical trial [pt] OR ran-
domized [tiab] OR placebo [tiab] OR
drug therapy [sh] OR randomly [tiab]
OR trial [tiab] OR groups [tiab]) NOT
(animals [mh] NOT humans [mh])
08:26:34 2267836
#39 Search HIV Infections[MeSH] OR
HIV[MeSH]
OR hiv[tw] OR hiv-1*[tw] OR hiv-
2*[tw] OR hiv1[tw] OR hiv2[tw] OR
hiv infect*[tw] OR human immun-
odeficiency virus[tw] OR human im-
munedeficiency virus[tw] OR human
immuno-deficiency virus[tw] OR hu-
man immune-deficiency virus[tw] OR
((human immun*) AND (deficiency
virus[tw])) OR acquired immunodefi-
ciency syndrome[tw] OR acquired im-
munedeficiency syndrome[tw] OR ac-
quired immuno-
08:26:21 267057
93Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
deficiency syndrome[tw] OR acquired
immune-deficiency syndrome[tw] OR
((acquired immun*) AND (deficiency
syndrome[tw])) OR ”sexually transmit-
ted diseases, viral“[MH]
Appendix 2. EMBASE SEARCH STRATEGY
No. Query Results Date
#6 #1 AND #2 AND #3 AND #4 AND
[humans]/lim AND [embase]/lim AND
[1980-2010]/py
146 28 Sept 2010
#5 #1 AND #2 AND #3 AND #4 181 28 Sept 2010
#4 intervention OR interventions OR ’risk
reduction’/de OR ’risk reduction’ OR
’risk reducing’ OR ’attitudes to health’
OR ’prevalence’/de OR prevalence OR
’incidence’/de OR incidence
1321732 28 Sept 2010
#3 ’prostitute’/de OR prostitute OR pros-
titutes OR ’prostitution’/de OR prosti-
tution OR ’sex worker’ OR ’sex workers’
OR ’callgirl’/de OR callgirl OR callgirls
7014 28 Sept 2010
#2 random*:ti OR random*:ab OR facto-
rial*:ti OR factorial*:ab OR cross?over*:
ti OR cross?over*:ab OR crossover*:ti
OR crossover*:ab OR placebo*:ti OR
placebo*:ab OR (doubl*:ti AND blind*:
ti) OR (doubl*:ab AND blind*:ab) OR
(singl*:ti AND blind*:ti) OR (singl*:ab
AND blind*:ab) OR assign*:ti OR as-
sign*:ab OR allocat*:ti OR allocat*:ab
OR volunteer*:ti OR volunteer*:ab OR
’crossover procedure’/exp OR ’crossover
procedure’/de OR ’crossover procedure’
OR ’double-blind procedure’/exp OR
’double-blind procedure’/de OR ’double-
blind procedure’ OR ’single-blind pro-
cedure’/exp OR ’single-blind procedure’/
de OR ’single-blind procedure’ OR ’ran-
domized controlled trial’/exp OR ’ran-
999275 28 Sept 2010
94Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
domized controlled trial’/de OR ’ran-
domized controlled trial’
#1 ’human immunodeficiency virus in-
fection’/exp OR ’human immunodefi-
ciency virus infection’/de OR ’human
immunodeficiency virus infection’ OR
’human immunodeficiency virus’/exp
OR ’human immunodeficiency virus’/
de OR ’human immunodeficiency virus’
OR hiv:ti OR hiv:ab OR ’hiv-1’:ti
OR ’hiv-1’:ab OR ’hiv-2’:ti OR ’hiv-
2’:ab OR ’human immunodeficiency
virus’:ti OR ’human immunodeficiency
virus’:ab OR ’human immuno-defi-
ciency virus’:ti OR ’human immuno-de-
ficiency virus’:ab OR ’human immuned-
eficiency virus’:ti OR ’human immuned-
eficiency virus’:ab OR ’human immune-
deficiency virus’:ti OR ’human immune-
deficiency virus’:ab OR ’acquired im-
mune-deficiency syndrome’:ti OR ’ac-
quired immune-deficiency syndrome’:ab
OR ’acquired immunedeficiency syn-
drome’:ti OR ’acquired immunedefi-
ciency syndrome’:ab OR ’acquired im-
munodeficiency syndrome’:ti OR ’ac-
quired immunodeficiency syndrome’:ab
OR ’acquired immuno-deficiency syn-
drome’:ti OR ’acquired immuno-defi-
ciency syndrome’:ab
315753 28 Sept 2010
H I S T O R Y
Protocol first published: Issue 2, 2005
Review first published: Issue 2, 2012
Date Event Description
15 February 2010 New citation required and major changes Made protocol a ”clean slate“ for new author team.
11 November 2008 Amended Converted to RevMan 5, and re-published without new citation
95Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C O N T R I B U T I O N S O F A U T H O R S
WW designed, set up, analysed, interpreted the data and drafted the review. EO designed, set up, and analysed the data. RM, AK, NH,
and KS revised the article. All authors read and approved the final version to be published.
D E C L A R A T I O N S O F I N T E R E S T
We declare that we have no conflict of interest.
S O U R C E S O F S U P P O R T
Internal sources
• Health Labour Sciences Research Grant, Japan.
External sources
• No sources of support supplied
D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W
Ai Koyanagi was involved as a co-author. She revised the draft and approved the final draft.
HIV/STI-related knowledge, sexual risk behavior, psychosocial barriers to condom use, drug and alcohol risk behavior were not listed
in the protocol. These were added as secondary outcomes as relevance to the review question regarding change individual behaviours
to prevent HIV infection.
Sensitivity analyses were not performed as there were too few trials under each comparison.
I N D E X T E R M S
Medical Subject Headings (MeSH)
∗Developing Countries [statistics & numerical data]; ∗Safe Sex; ∗Sex Workers [statistics & numerical data]; Cognitive Therapy
[∗methods]; Condoms [utilization]; HIV Infections [epidemiology; ∗prevention & control; transmission]; Incidence; Randomized
Controlled Trials as Topic; Social Behavior
MeSH check words
Adult; Female; Humans; Male
96Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income
countries (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.