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      Population size estimation of female sex workers in Iran: Synthesis of methods and results

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          Abstract

          Introduction

          Estimating the number of key populations at risk of HIV is essential for planning, monitoring, and evaluating prevention, care, and treatment programmes. We conducted this study to estimate the number of female sex workers (FSW) in major cities of Iran.

          Methods

          We used three population size estimation methods (i.e., wisdom of the crowds, multiplier method, and network scale-up) to calculate the number of FSW in 13 cities in Iran. The wisdom of the crowds and multiplier methods were integrated into a nationwide bio-behavioural surveillance survey in 2015, and the network scale-up method was included in a national survey of the general population in 2014. The median of the three methods was used to calculate the proportion of the adult female population who practice sex work in the 13 cities. These figures were then extrapolated to provide a national population size estimation of FSW across urban areas.

          Results

          The population size of FSW was 91,500 (95% Uncertainty Intervals [UIs] 61,400–117,700), corresponding to 1.43% (95% UIs 0.96–1.84) of the adult (i.e., 15–49 year-old) female population living in these 13 cities. The projected numbers of FSW for all 31 provincial capital cities were 130,800 (95% UIs 87,800–168,200) and 228,700 (95% UIs 153,500–294,300) for all urban settings in Iran.

          Conclusions

          Using methods of comparable rigor, our study provided a data-driven national estimate of the population size of FSW in urban areas of Iran. Our findings provide vital information for enhancing HIV programme planning and lay a foundation for assessing the impact of harm reduction efforts within this marginalized population.

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          Most cited references20

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          Estimates of the number of female sex workers in different regions of the world.

          To collect estimated numbers of female sex workers (FSW) and present proportions of FSW in the female population (FSW prevalence) in different regions of the world. Subnational and national estimated numbers of FSW reported in published and unpublished literature, as well as from field investigators involved in research or interventions targeted at FSW, were collected. The proportion of FSW in the adult female population was calculated. Subnational estimates were extrapolated to national estimates if appropriate. Population surveys were scanned for proportions of adult women having sex in exchange for money or goods. In sub-Saharan Africa, the FSW prevalence in the capitals ranged between 0.7% and 4.3% and in other urban areas between 0.4% and 4.3%. Population surveys from this same region yielded even higher proportions of women involved in transactional sex. The national FSW prevalence in Asia ranged between 0.2% and 2.6%; in the ex-Russian Federation between 0.1% and 1.5%; in East Europe between 0.4% and 1.4%; in West Europe between 0.1% and 1.4%; and in Latin America between 0.2% and 7.4%. Estimates from rural areas were only available from one country. Although it is well known and accepted that FSW are a highly vulnerable group in the scope of the HIV epidemic, most countries in the world do not know the size of this population group. The estimates of the prevalence of FSW presented in this paper show how important this hard-to-reach population group is in all parts of the world.
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            Estimating the size of key populations: current status and future possibilities.

            Estimation of key population sizes is essential for advocacy, program planning, and monitoring of HIV epidemics in these populations. A review of recent publications on population size estimation among key populations including MSM, people who inject drugs, and male and female sex workers was conducted to identify and assess current practices at the global level.
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              Incorporating the service multiplier method in respondent-driven sampling surveys to estimate the size of hidden and hard-to-reach populations: case studies from around the world.

              Estimating the sizes of populations at highest risk for HIV is essential for developing and monitoring effective HIV prevention and treatment programs. We provide several country examples of how service multiplier methods have been used in respondent-driven sampling surveys and provide guidance on how to maximize this method's use. Population size estimates were conducted in 4 countries (Mauritius- intravenous drug users [IDU] and female sex workers [FSW]; Papua New Guinea-FSW and men who have sex with men [MSM]; Thailand-IDU; United States-IDU) using adjusted proportions of population members reporting attending a service, project or study listed in a respondent-driven sampling survey, and the estimated total number of population members who visited one of the listed services, projects, or studies collected from the providers. The median population size estimates were 8866 for IDU and 667 for FSW in Mauritius. Median point estimates for FSW were 4190 in Port Moresby and 8712 in Goroka, Papua New Guinea, and 2,126 for MSM in Port Moresby and 4200 for IDU in Bangkok, Thailand. Median estimates for IDU were 1050 in Chiang Mai, Thailand, and 15,789 in 2005 and 15,554 in 2009 in San Francisco. Our estimates for almost all groups in each country fall within the range of other regional and national estimates, indicating that the service multiplier method, assuming all assumptions are met, can produce informative estimates. We suggest using multiple multipliers whenever possible, garnering program data from the widest possible range of services, projects, and studies. A median of several estimates is likely more robust to potential biases than a single estimate.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                10 August 2017
                2017
                : 12
                : 8
                Affiliations
                [1 ] HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
                [2 ] Department of Biostatistics and Epidemiology, Faculty of Public Health, Kerman University of Medical Sciences, Kerman, Iran
                [3 ] School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
                [4 ] Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
                [5 ] Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada
                [6 ] Global Health Sciences, University of California, San Francisco, California, United States of America
                [7 ] Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
                Hokkaido University Graduate School of Medicine, JAPAN
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-17-04202
                10.1371/journal.pone.0182755
                5552099
                28796847
                3c5ced12-3d4d-4a71-bc0b-26c024b4282c
                © 2017 Sharifi et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 2, Tables: 3, Pages: 12
                Product
                Funding
                Funded by: Ministry of Health, Iran
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
                Award ID: R25 MH064712
                Award Recipient :
                Funded by: National Institute of Mental Health (US)
                Award ID: R25 MH064712
                Award Recipient :
                Funded by: The Global Fund to Fight AIDS, Tuberculosis and Malaria
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
                Award ID: R25 MH064712
                Award Recipient :
                The NSU project was supported by the Ministry of Health (Iran); the IBBS project was supported by United Nations Development Programmeme – The Global Fund to Fight AIDS, Tuberculosis and Malaria. We also wish to acknowledge the support from the University of California, San Francisco’s International Traineeships in AIDS Prevention Studies (ITAPS), U.S. NIMH, R25 MH064712 and UCSF Open Access Publishing Fund. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                People and Places
                Geographical Locations
                Asia
                Iran
                Social Sciences
                Sociology
                Sexual and Gender Issues
                Sex Work
                People and Places
                Population Groupings
                Professions
                Sex Workers
                Female Sex Workers
                People and Places
                Population Groupings
                Age Groups
                Adults
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Biology and Life Sciences
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                Immunodeficiency Viruses
                HIV
                Biology and Life Sciences
                Organisms
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                HIV
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                Organisms
                Viruses
                RNA viruses
                Retroviruses
                Lentivirus
                HIV
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Computer and Information Sciences
                Network Analysis
                Social Networks
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                Public and occupational health
                Preventive medicine
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                Epidemiology
                HIV epidemiology
                Custom metadata
                The Ministry of Health and Medical Education of Iran owns the data. Data will be available upon request submitted to info@ 123456hivhub.org (the HIV/STI Surveillance Research Center) for researchers who meet the criteria for accessing confidential data in the Ministry of Health and Medical Education of Iran. The Ministry of Health and Medical Education owns data. Sex work is highly stigmatized and currently illegal in Iran. To protect the study population, all individual-level data on their size and risk behaviors are being considered sensitive data. It is required that all researchers who wanted to work on this data submit their data request access to info@ 123456hivhub.ir (the HIV/STI Surveillance Research Center). However, for this paper, the group-level data that we used for population size estimation are presented in the supplementary documents.

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