Dual contraceptive use among female sex workers in high HIV-burden settings in sub-saharan Africa: A systematic review and meta-analysis

Background Female sex workers (FSWs) in sub-Saharan Africa (SSA) face higher risks of unintended pregnancies and sexually transmitted infections, including HIV. This risk can be reduced with correct and consistent use of dual contraception, defined as the concurrent use of a barrier method together with another modern contraceptive methods. However, there are limited and fragmented data on the prevalence and factors associated with dual contraception use among FSWs in SSA. Objectives Our systematic review and meta-analysis aimed to determine the pooled prevalence of dual contraceptive use and HIV infection prevalence among FSWs in the high HIV-burden settings of SSA. Design A systematic review and meta-analysis. Data sources and methods We conducted a comprehensive search of PubMed, MEDLINE, EMBASE, Web of Science, and African Journal Online, from January 1980 up to October 2023. We also reviewed bibliographies of relevant articles to find additional studies. Only observational and interventional studies reporting dual contraceptive use among FSWs in Africa were included, while reviews, case reports, and case series were excluded. Two reviewers evaluated study quality using the modified Newcastle-Ottawa Scale. Data on dual contraceptive use, contraceptives methods, associated factors and HIV prevalence were extracted and analysed using random-effect or fixed-effect meta-analysis models to calculate the pooled prevalence estimates defined as combined average estimates across studies. Results We included 11 studies, involving a total of 127,059FSWs from eight countries in SSA. HIV prevalence ranged from 1-55% across studies, with a pooled prevalence of 24% (95% confidence interval (CI): 14-35%, I 2 = 99.57%, p<0.001). Dual contraception prevalence ranged from 3.8-66.2% across studies, with a pooled prevalence of 26% (95% CI: 12% – 39%, I 2 =99.9%, p<0.001). The most frequently reported contraceptive method were condoms (n=41,200,32.1%) and oral contraceptive pills (n=20,735, 16.5%), followed by injectables (n=6,349, 5.1%), Implants (n=5,430, 4.3%) and intrauterine device (n=601, 0.5%). Conclusions Dual contraceptive utilization remains sub-optimal among FSWs in SSA, with fewer than one in three FSWs utilising this essential reproductive health strategy. Moreover, HIV prevalence remains high in this population. Targeted strategies to improve utilisation of dual contraception among this marginalised population is needed to reduce the risks of unintended pregnancies, HIV infection and other STIs and their negative impacts on FSWs, their clients, families and the entire healthcare systems.