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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 Subnational and national estimated numbers of FSW reported in published and unpublished literature, as well as from field investigators involved in research or interventions targeted at FSW, were collected.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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              HIV prevalence and related risk behaviours among female sex workers in Iran: results of the national biobehavioural survey, 2010

              Objectives To determine the prevalence of HIV and related behavioural risks among Iranian female sex workers (FSW) via the first national biobehavioural surveillance survey. Methods In 2010, 1005 FSW were approached and 872 recruited using facility-based sampling from 21 sites in 14 cities in Iran. We collected dried blood samples and conducted face-to-face interviews using a standardised questionnaire. Data were weighted based on the response rate and adjusted for the clustering effect of the sampling site. Adjustment was performed by weighting based on the sampling fraction of each site using a prior estimate of its total size of the FSW population. Results The prevalence of HIV infection (95% CI) was 4.5% (2.4 to 8.3) overall, 4.8% (2.2 to 9.8) among those who had reported a history of drug use and 11.2% (5.4 to 21.5) among those who had a history of injection drug use. The frequencies of condom use in the last sexual act with paying clients and non-paying partners were 57.1% and 36.3%, respectively. Any drug use was reported by 73.8% of participants, and among this subgroup, 20.5% had a history of injection drug use. Conclusions The prevalence of HIV was considerable among FSW particularly those who had a history of drug injection. A combination of prevention efforts addressing unsafe sex and injection are needed to prevent further transmission of HIV infection.
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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
                : e0182755
                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.

                Author information
                http://orcid.org/0000-0002-0478-3220
                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.

                History
                : 1 February 2017
                : 24 July 2017
                Page count
                Figures: 2, Tables: 3, Pages: 12
                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
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                Sex Workers
                Female Sex Workers
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                Biology and Life Sciences
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                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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