HIV pre-exposure prophylaxis care continuum among female sex-workers in sub-Saharan Africa: a systematic review

Background: Female sex workers (FSWs) are disproportionately affected by the HIV epidemic in sub-Saharan Africa (SSA). Pre-exposure prophylaxis (PrEP) is a relatively novel approach in SSA recommended to complement the existing combination prevention methods for such high risk populations. The PrEP care continuum including awareness, acceptability, uptake, adherence and retention in care is affected by varying contextual factors in the region. Our review aimed to synthesize existing evidence regarding such factors in order to suggest evidence-based interventions. Methods : We conducted a systematic review of observational quantitative studies and qualitative studies assessing factors affecting one or more components of the continuum. We searched Medline, PubMed, CINAHL and Web of Science databases on 12 June 2024, and grey literature through Google Scholar on 23 December 2024. We used the Cochrane “Risk of bias” tool for non-randomised studies to assess risk of bias in quantitative studies, and the JBI Critical Appraisal Checklist for Qualitative Research in qualitative studies. Given a great methodological heterogeneity among included studies, we provided a narrative synthesis of both quantitative and qualitative findings. This review is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD420250650765). Results : Of 904 articles retrieved from all sources, 53 were eligible for inclusion in the review. Among these, 35 studies were quantitative, 15 qualitative and the remaining three were mixed-methods studies. Fourteen studies assessed level of awareness/knowledge about PrEP and the results ranged from 8% to 96%. Level of PrEP acceptability was assessed by twelve studies and was found to be generally high (>90% in most cases) whereas a relatively moderate uptake was reported by eighteen studies (>50% in most cases) and lower current use (generally <50%) as reported by six studies. Ten studies reported on level of PrEP adherence and in all cases it was lower than “the protective level adherence” (i.e. >85%) and showed a decreasing pattern as follow-up time increased. Retention in care was assessed by nine studies in which it varied greatly across studies (from 32% to 92% at first month) and declined sharply over time. In addition to limited awareness due to the novelty of PrEP, factors including perceptions of HIV risk and responsibility and life aspiration; social support and stigma; accessibility of non-judgmental services; and concerns regarding drug side-effects and pill burden were reported as determinants of PrEP continuum. Conclusions : Our findings suggest that the PrEP care continuum among FSWs in SSA can be improved through adapting best practices and implementation of differentiated and user-centred delivery approaches and product modalities supported by continuous risk assessment and community engagement.