Researchers searched MEDLINE, Embase and PsycINFO for studies published from January 1, 2010, through June 9, 2026, without restricting language or study design. Eligible studies assessed physical, sexual, emotional or psychological, and financial violence, either during the previous year or over a lifetime. The outcomes were prevalent and incident HIV infection, HIV testing, antiretroviral therapy use, treatment adherence and viral suppression. Multi-level random-effects meta-analyses pooled the available estimates, with adjusted estimates preferred when studies reported both adjusted and unadjusted results.

The clearest association was between violence and HIV prevalence. Female sex workers reporting violence in the previous year had 31% higher pooled odds of prevalent HIV infection, with a pooled odds ratio of 1.31 and a 95% confidence interval of 1.16 to 1.48. This comparison drew on 75 estimates, and statistical heterogeneity was 63%. Lifetime violence was associated with 35% higher pooled odds of HIV prevalence, with an odds ratio of 1.35, a 95% confidence interval of 1.23 to 1.48 and 68 contributing estimates; heterogeneity for this result was 39%.

Stratification by type of violence showed the strongest pooled associations for sexual violence. Recent sexual violence was associated with 55% higher odds of HIV prevalence, producing a pooled odds ratio of 1.55 with a 95% confidence interval of 1.24 to 1.94. The estimate included 28 contributing estimates and had heterogeneity of 69%. Lifetime sexual violence was associated with 40% higher odds, with a pooled odds ratio of 1.40, a 95% confidence interval of 1.21 to 1.63 and 28 estimates. Its heterogeneity was 47%, indicating variation among the pooled results.

Violence in the previous year was also associated with reduced odds of antiretroviral therapy use. Seventeen estimates contributed to a pooled odds ratio of 0.78, equivalent to 22% lower odds, with a 95% confidence interval of 0.64 to 0.94. Heterogeneity was 8% for this association. Among women reporting lifetime violence, the pooled odds of viral suppression were lower, with an odds ratio of 0.88 and a 95% confidence interval of 0.79 to 0.98. Six estimates contributed to that result, which had 20% heterogeneity.

The review found no evidence of pooled associations between violence and HIV incidence, HIV testing or antiretroviral therapy adherence. That finding does not demonstrate that no such relationships exist. The studies differed in design, populations, violence definitions and outcome measurement, while experiences of violence can be difficult to measure consistently. The absence of a detected pooled association therefore should be interpreted separately from the statistically significant findings for HIV prevalence, therapy use and viral suppression.

The evidence base was geographically broad but unevenly distributed. Of the 94 included studies, 47 were based in low- and middle-income countries, representing 50% of the total, while 18 were conducted in low-income countries, representing 19%. Most of the included research was cross-sectional, measuring violence and HIV-related outcomes at approximately the same time. This limits the review’s ability to determine whether violence preceded an infection or treatment outcome. Heterogeneity among the pooled estimates and difficulties in measuring violence were additional limitations, and some studies contributed multiple estimates because they reported several exposures or outcomes.

Taken together, the synthesis identifies experiencing violence as a structural determinant associated with HIV outcomes among female sex workers. The higher pooled prevalence observed after both recent and lifetime violence, together with the strongest type-specific associations for sexual violence, shows that the pattern extended across different exposure windows and forms of violence. The findings support treating violence as part of the conditions shaping HIV prevention and care rather than as an issue separate from them, although the observational evidence does not by itself prove that violence caused the measured differences.

Subject of Research: Associations between violence and HIV outcomes among female sex workers worldwide

Article Title: Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis

Article References: Dawe, J., Mazhar, K. A., Khan, S. A., Njiro, B. J., Bendaud, V., Sabin, K., Ambia, J., Trickey, A., Barrass, L., Asgharzadeh, A., Stone, J., Artenie, A., & Vickerman, P. (2026). Impact of violence on HIV outcomes among female sex workers: A global systematic review and meta-analysis. PLOS Medicine, 23(10), e1004977. https://doi.org/10.1371/journal.pmed.1004977

Image Credits: AI Generated

DOI: 10.1371/journal.pmed.1004977

Keywords: HIV, female sex workers, violence, systematic review, meta-analysis, HIV prevalence, antiretroviral therapy, viral suppression, sexual violence, global health, Impact, outcomes

The findings arrive at a critical moment for global HIV policy. UNAIDS has set the ambitious target of ending AIDS as a public health threat by 2030, and a central pillar of that strategy is the so-called 95-95-95 cascade: by 2030, 95 percent of people living with HIV should know their status, 95 percent of those diagnosed should be on sustained ART, and 95 percent of those on treatment should achieve viral suppression. Knowledge of HIV status is the essential first step in this cascade, because without a diagnosis people cannot begin treatment, cannot achieve an undetectable viral load, and cannot benefit from the dramatic reductions in morbidity and mortality that modern antiretroviral regimens provide. Population surveys that offer testing to every participant, regardless of what they report about their own history, are among the most reliable ways to measure progress toward that first 95 percent target, since they do not rely solely on what people remember or are willing to disclose.

Kyamulibwa is an ideal setting for such an assessment. The sub-county hosts a long-running population cohort established by the Uganda Virus Research Institute, and HIV prevalence there has remained high and sustained for years, making it representative of rural settings in the region where the epidemic is generalised, meaning transmission occurs widely in the general population rather than being concentrated in specific groups. The survey team approached residents across 25 villages and achieved remarkable coverage of the biomedical component of the study: every participant consented to HIV testing, and 99.9 percent of those tested received a result. This near-universal acceptance of testing within the survey itself is a striking contrast with the gaps in routine testing uptake that the survey uncovered, and it demonstrates that when testing is offered directly and confidentially in a trusted community setting, people are willing to learn their status.

The headline result is a mixed picture. Among survey participants found to be living with HIV, 83.6 percent of men and 88.0 percent of women already knew their status before the survey test. These figures fall short of the 95 percent target that UNAIDS has set for 2030, and they quantify the remaining diagnostic gap in a rural African setting with a mature epidemic. Yet the study also delivered an encouraging finding about the second stage of the cascade: among those who knew they were living with HIV, 99 percent of both men and women reported taking ART. This near-universal treatment uptake among the diagnosed suggests that once people in this community learn their status, they overwhelmingly engage with care, pointing to high acceptance of treatment and good availability of antiretroviral drugs in the local health system. The bottleneck, in other words, is not treatment provision but diagnosis.

HIV prevalence among survey participants was 8.1 percent among men and 10.5 percent among women, figures consistent with a sustained, generalised epidemic in which roughly one in ten adults carries the virus. At this level of prevalence, the researchers note, reliable access to sufficient ART is essential not only for the health of the individuals on treatment but for the community as a whole, because viral suppression among treated individuals dramatically reduces onward transmission. The high proportion of diagnosed individuals reporting ART use is therefore doubly significant: it protects the nearly one in ten residents living with HIV and supports the broader goal of bringing the epidemic under control.

One of the most consequential findings concerns the people who had never been tested. Among all survey participants, 39.7 percent of men and 28.7 percent of women reported that they had never previously tested for HIV. That such a large share of the adult population had never come into contact with HIV testing services, even in a community with decades of epidemic experience and active research infrastructure, underscores how unevenly testing reaches rural populations. The researchers found that never having tested was associated with older age, male sex, lower educational attainment and never having been married. Each of these associations points to a distinct mechanism of exclusion from health services, and together they sketch a profile of the individuals most likely to be missed by routine testing campaigns.

The association with male sex is particularly notable, because men in sub-Saharan Africa are consistently underrepresented in HIV testing and treatment cascades, a pattern often attributed to health services that are designed around maternal and child health clinics, to masculine norms that discourage help-seeking, and to employment patterns that keep men away from facilities during opening hours. The association with older age suggests that people who reached adulthood before the era of universal test-and-treat policies may never have been systematically offered testing, and that testing campaigns may disproportionately reach younger adults through school-linked, antenatal and youth-oriented services. Lower education likely reflects barriers of health literacy, awareness of services and confidence navigating the health system, while never having been married may indicate weaker contact with services that are often accessed through household or family pathways.

Crucially, the study found that the large group of never-tested individuals did not represent a large reservoir of undiagnosed infection. Among participants who had never previously tested, only 2.5 percent of men and 2.7 percent of women received a positive diagnosis in the survey. Because HIV prevalence in the community is far higher than this, the mathematics of the epidemic imply that most people living with HIV had already been tested at some point and knew their status, while the never-tested group was composed predominantly of people who were HIV-negative. This is an important nuance for programme planners: the diagnostic gap in Kyamulibwa is not primarily a matter of finding large numbers of undiagnosed infections hiding among the never-tested, but rather of the roughly 12 to 16 percent of people living with HIV who had tested at some point yet either did not learn their result, did not retain the knowledge, or did not report it accurately.

The distinction matters for strategy. If the undiagnosed fraction of people living with HIV were concentrated among never-testers, then simply expanding testing volume and reaching first-time testers would close most of the gap. Instead, the data suggest that interventions must also address people who have had contact with testing services but remain unaware of or have not disclosed their status, as well as the specific demographic groups, older men, people with less education and unmarried adults, whose participation in testing needs to increase. Tailored approaches might include community-based and home-based testing that reaches men where they live and work, index testing that offers screening to the contacts of diagnosed individuals, and integration of HIV testing into services that older and unmarried adults already use. Self-testing kits, which allow people to test privately before confirming at a clinic, represent another avenue that has expanded across the region since the survey period.

The study’s authors frame their results against the UNAIDS 2030 targets, and the arithmetic is sobering: with 83.6 percent of men and 88.0 percent of women living with HIV aware of their status, the community would need to close a gap of roughly seven to eleven percentage points to reach the first 95. In a generalised epidemic with prevalence above eight percent, each percentage point represents a substantial number of individuals who could start treatment, achieve viral suppression and protect their partners. At the same time, the near-universal ART uptake among the diagnosed, and the near-universal acceptance of testing when offered within the survey, are grounds for optimism. They indicate that the demand for and acceptance of HIV services in this rural Ugandan population are strong, and that the remaining challenge is one of reach and equity, ensuring that testing opportunities extend to the older, less educated, male and unmarried residents whom existing services have not fully engaged. As the 2030 deadline approaches, studies like this one, grounded in decades of community-level research infrastructure, provide exactly the granular evidence that national programmes and global funders need to direct resources where the diagnostic gap actually lies.

Subject of Research: Knowledge of HIV status and antiretroviral therapy uptake in a rural Ugandan population with a sustained generalised HIV epidemic

Article Title: Knowledge of HIV status in a rural Ugandan population with a sustained, generalised HIV epidemic

Article References: Tomlin, K., Makanga, R., Seeley, J., Slaymaker, E., Newton, R., & Mugisha, J. (2026). Knowledge of HIV status in a rural Ugandan population with a sustained, generalised HIV epidemic. PLOS Global Public Health, 6(10), e0007354. https://doi.org/10.1371/journal.pgph.0007354

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0007354

Keywords: HIV, Uganda, HIV testing, antiretroviral therapy, UNAIDS 95-95-95 targets, HIV prevalence, rural health, generalised epidemic, knowledge of HIV status, Kyamulibwa, PLOS Global Public Health, treatment cascade

The scale of the challenge is considerable. Nigeria is home to roughly two million people living with HIV, the second-largest such population in the world. With the global target of ending HIV/AIDS set for 2030, the authors note that only a few years remain, and a single policy factor continues to compromise that timeline: the legal treatment of sex work as a criminal matter. Nigeria’s legal landscape is fragmented, with southern states punishing allied activities such as pimping and brothel-keeping, while northern states, applying versions of Sharia law, criminalise prostitution outright. This patchwork, the authors argue, creates an environment in which poor health outcomes and economic inefficiency flourish together.

The epidemiological logic of the critique is straightforward. Criminalisation drives sex work underground, where stigma and the persistent fear of arrest deter people from seeking HIV testing, prevention tools, and treatment. Studies cited in the commentary document that sex workers in Nigeria are frequently refused care by healthcare providers and routinely avoid health services out of fear of police encounters. This is despite the existence of the Nigerian HIV and AIDS (Anti-Discrimination) Act of 2014, which was intended to prohibit discrimination based on real or perceived HIV status. In practice, the authors observe, sex workers remain discriminated against by the very systems that are supposed to protect them, and enforcement activities themselves are associated with violence, extortion, and human rights abuses.

The numbers illustrate the consequences. A 2023 review of HIV trends in Nigeria reported a cumulative HIV prevalence of 10.8 percent among key populations in Kano State, dramatically higher than in the general population, with stigma and insufficient services identified as major barriers to care. Because criminalisation obstructs access to the very interventions that prevent and treat HIV, the commentary argues, it directly drives new infections and keeps the epidemic concentrated and expensive to manage. Treating advanced HIV disease, managing opportunistic infections, and funding long-term antiretroviral therapy and hospitalisations cost far more than preventive care would, meaning the current legal framework effectively forces Nigeria to spend more money for worse outcomes.

The fiscal dimension is central to the authors’ case. The Nigerian government and major international funders, including PEPFAR and the Global Fund, have invested heavily in HIV prevention programmes. Yet when one of the most vulnerable populations cannot safely access those programmes, the return on investment collapses. Police raids, detentions, and the cost of running detention facilities for arrested sex workers consume taxpayer money and law-enforcement capacity that the authors describe as counterproductive, straining an already overstretched judicial system. Decriminalisation, by contrast, would relieve pressure on the courts and police, freeing funds that could be redirected toward healthcare and reducing the sexual and gender-based violence documented during law-enforcement operations.

The commentary is careful to distinguish decriminalisation from legalisation, a distinction with significant practical implications for Nigeria. Legalisation typically involves formal state regulation through registration and licensing schemes, which can improve labour standards in theory but, in a politically conservative society, risks driving sex workers further underground if they are unwilling to identify themselves to authorities. Decriminalisation, as defined by the Global Network of Sex Work Projects, means the complete removal of criminal and administrative penalties against the sale and purchase of sex, advertising, solicitation, and third-party involvement, eliminating extraordinary policing and surveillance. International evidence, including a major global epidemiological review published in The Lancet, links decriminalisation to reduced HIV risk environments and increased uptake of services among sex workers, making it the more context-appropriate reform for Nigeria.

From a programmatic standpoint, decriminalisation would transform how prevention reaches the population that needs it most. The authors point to evidence that Nigerian sex workers are eager to engage with prevention: in one recent study, 95.9 percent obtained HIV testing when it was available, and 68 percent used pre-exposure prophylaxis, or PrEP, when it was accessible. Removing the threat of arrest would allow health authorities to systematically supply and track tools such as PrEP and condoms, and to establish regular testing within sex worker communities rather than relying on ad hoc, low-trust outreach. Instead of being treated as a public health liability, sex workers would be integrated into the healthcare system, with unhindered access to sexual and reproductive health programmes.

The economic argument extends beyond the health budget. The authors highlight an emerging contradiction in Nigerian policy: recent government proposals to tax all income, including earnings from sex work, sit awkwardly alongside laws that criminalise that same income. Decriminalisation would resolve this contradiction, bringing an active segment of the informal economy into the tax base and generating revenue that could be invested in public health programmes, including HIV prevention and sexual health clinics. Economic empowerment effects would follow, the authors argue, as sex workers gained the ability to demand fair pay and safer working conditions, spend less on bribes to law enforcement, negotiate condom use more effectively, refuse dangerous clients, and reduce their exposure to violence and abuse.

The commentary also addresses a common counterargument: that economic and educational exit programmes are a preferable empowerment strategy in conservative societies. The authors acknowledge that such programmes can help some women transition out of sex work, citing studies from Africa and Canada, but note that in criminalised environments their effectiveness is limited by legal precarity, violence, and stigma, and that the best results come from integrated, voluntary, rights-based support rather than stand-alone exit mandates. Decriminalisation, in their framing, is best understood as a structural harm-reduction reform that enhances the reach and effectiveness of every other intervention.

Ultimately, the authors present Nigeria with a clear choice. The country can continue along an expensive and futile path of criminalisation that feeds the epidemic it claims to fight, or it can adopt a realistic, health-centred policy of decriminalisation. They are explicit that decriminalising sex work should not be read as an endorsement of the profession but as an acknowledgement that containing HIV requires unimpeded access to prevention and care, unobstructed by law. Framed as an investment in public health, the reform promises lower infection rates, more efficient use of national and donor funds, and meaningful progress toward ending AIDS by 2030. From a health economics standpoint, the authors conclude, it is an investment Nigeria cannot afford to postpone.

Subject of Research: Health economics analysis of sex work decriminalisation and its impact on HIV prevalence in Nigeria

Article Title: Decriminalising sex work and the health economics impact on HIV prevalence in Nigeria

Article References: Olarewaju, A. A., & Riki, S. T. (2026). Decriminalising sex work and the health economics impact on HIV prevalence in Nigeria. Discover Social Science and Health, 6(1), Article 106. https://doi.org/10.1007/s44155-026-00452-0

Image Credits: AI Generated

DOI: 10.1007/s44155-026-00452-0

Keywords: sex work decriminalisation, HIV prevalence, Nigeria, health economics, PrEP, HIV prevention, key populations, stigma, public health policy, harm reduction, PEPFAR, Global Fund