Implementing HIV pre-exposure prophylaxis (PrEP) among cisgender female sex workers: A worldwide scoping review to guide the future research agenda for HIV prevention

Female sex workers (FSWs) experience a disproportionately high burden of HIV. To inform future research and policy efforts on HIV prevention, this study synthesizes global evidence on HIV pre-exposure prophylaxis (PrEP) among cisgender FSWs worldwide. This scoping review was conducted using six multidisciplinary databases searched up to December 2024. Titles and abstracts, then full texts, were independently screened. Data extraction comprised i) general study characteristics (UNAIDS region, country, study type, outcomes, type of PrEP, and study years), ii) detailed data of each outcome (including PrEP knowledge, a priori acceptability – interest, and effective acceptability – use, retention and adherence). Drivers and barriers to PrEP acceptability were analyzed using an adapted conceptual framework encompassing six domains: patient characteristics, individual knowledge and perceptions, medication-related factors, social processes, structural and health system factors, and sex work characteristics. After selection, 120 eligible studies were identified, mostly conducted in Eastern and Southern Africa. PrEP knowledge was initially low but increased quickly once programs were introduced. PrEP interest was consistently high across regions, driven by perceived HIV risk and desire for self‑protection. PrEP uptake, retention and adherence varied widely. Main barriers included sex work realities (i.e., unstable housing, alcohol use), social processes (i.e., stigma), individual characteristics (i.e., mobility), treatment-related characteristics (i.e., side effects), and health system challenges (i.e., clinic access constraints). Drivers included social support and reminder tools. While evidence on long‑acting PrEP remained limited, interest was consistently high as reducing daily burden. Overall, the findings support a socio-ecological understanding of PrEP engagement among FSWs, including the sex work context as a distinct intermediary layer. They highlight the need for differentiated and structurally responsive PrEP delivery models tailored to the realities of sex work. Expanding long‑acting PrEP options and improving service accessibility, community engagement, and stigma reduction strategies will be critical to strengthening HIV prevention among FSWs globally.