Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low‐ and middle‐income countries

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 s, CINAHL, Dissertation International (DAI), EMBASE, LILACS, BIOSIS, SciSearch, INDMED, Proquest, and various South Asian ing 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 interventions 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. 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) com