HIV pre-exposure prophylaxis care continuum among female sex-workers in sub-Saharan Africa: a systematic review

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Pre-exposure prophylaxis (PrEP) is a relatively novel approach in SSA recommended to complement the existing combination prevention methods for such high risk populations. The PrEP care continuum including awareness, acceptability, uptake, adherence and retention in care is affected by varying contextual factors in the region. Our review aimed to synthesize existing evidence regarding such factors in order to suggest evidence-based interventions. Methods : We conducted a systematic review of observational quantitative studies and qualitative studies assessing factors affecting one or more components of the continuum. We searched Medline, PubMed, CINAHL and Web of Science databases on 12 June 2024, and grey literature through Google Scholar on 23 December 2024. We used the Cochrane “Risk of bias” tool for non-randomised studies to assess risk of bias in quantitative studies, and the JBI Critical Appraisal Checklist for Qualitative Research in qualitative studies. Given a great methodological heterogeneity among included studies, we provided a narrative synthesis of both quantitative and qualitative findings. This review is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD420250650765). Results : Of 904 articles retrieved from all sources, 53 were eligible for inclusion in the review. Among these, 35 studies were quantitative, 15 qualitative and the remaining three were mixed-methods studies. Fourteen studies assessed level of awareness/knowledge about PrEP and the results ranged from 8% to 96%. Level of PrEP acceptability was assessed by twelve studies and was found to be generally high (>90% in most cases) whereas a relatively moderate uptake was reported by eighteen studies (>50% in most cases) and lower current use (generally 85%) and showed a decreasing pattern as follow-up time increased. Retention in care was assessed by nine studies in which it varied greatly across studies (from 32% to 92% at first month) and declined sharply over time. In addition to limited awareness due to the novelty of PrEP, factors including perceptions of HIV risk and responsibility and life aspiration; social support and stigma; accessibility of non-judgmental services; and concerns regarding drug side-effects and pill burden were reported as determinants of PrEP continuum. Conclusions : Our findings suggest that the PrEP care continuum among FSWs in SSA can be improved through adapting best practices and implementation of differentiated and user-centred delivery approaches and product modalities supported by continuous risk assessment and community engagement. pre-exposure prophylaxis care continuum factors female sex workers sub-Saharan Africa Figures Figure 1 Introduction Globally, female sex-workers (FSWs) are disproportionately affected by the epidemic of Human Immunodeficiency virus (HIV). Reported HIV prevalence in FSWs has exceeded that of other women of reproductive age by more than 13 times, with greater than half of FSWs found to be infected in some settings in sub-Saharan Africa (SSA) [ 1 – 3 ]. A number of behavioural, social and regulatory factors contribute to the higher risk of HIV in FSWs, particularly in the context of SSA. Substance abuse, violence, social marginalization and criminalization of sex work all weaken FSW’s ability to effectively use protective methods and increase their vulnerability to HIV-infection [ 2 , 4 – 9 ]. Pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV-negative individuals for preventing acquisition of the infection, has emerged as a biomedical prevention method demonstrating high efficacy and safety across different population groups and exposure types [ 10 – 13 ]. PrEP enhances self-protection among FSWs and provides an additional layer of protection along with other barrier methods such as condoms - which are effective only when both parties have the self-efficacy and commitment to consistently and appropriately use it, and may sometimes only be used subject to client approval [ 1 , 5 , 14 ]. Many SSA countries officially endorsed offering PrEP to FSWs following the 2015 World Health Organization (WHO) recommendations for its use as part of combination HIV prevention for sexually active individuals at substantial risk of HIV infection - HIV incidence greater than 3 per 100 person–years in the absence of PrEP [ 15 ]. However, PrEP scale-up has been inadequate in the region [ 16 – 19 ] adversely affecting the expected impact of the programme on the epidemic by reducing the burden of the disease on key populations such as FSWs, which could ultimately contribute to the prevention of community transmissions. The progression of a PrEP programme can effectively be evaluated by examining each step that the care process entails. Nunn and colleagues [ 20 ] proposed an expanded framework of PrEP care continuum to measure PrEP awareness, uptake, adherence, and retention in care. We adapted this framework to describe the situation of the PrEP care cascade (including awareness about PrEP, acceptability/willingness to use, uptake/actual use, adherence and retention in care) among FSWs in the SSA context. Despite the fact that awareness is critical for engagement in the next stages of the care cascade, FSWs in SSA generally have low awareness about the existence and health importance of PrEP [ 21 – 23 ]. This might partly reflect the relative novelty of the method in the region and insufficient mobilization and education efforts in the target population. When adequately informed about its nature and role, however, FSWs often indicate high willingness to use [ 24 , 25 ]. Despite the indications of acceptance, the actual use (uptake) is very low due to a range of personal, social and structural barriers including: low risk perception, social stigma related to both sex work and HIV, lack of social support and limited access [ 22 , 26 ]. Poor adherence and inappropriate discontinuations (discontinuation of PrEP care being considered appropriate when there is low/no risk of infection) are high among those who initiated [ 24 , 27 ], substantially hindering efficacy of the method which is highly dependent on optimal adherence [ 13 ]. Moreover, a lack of standardised targets similar to those for HIV diagnosis and treatment, and limited implementation of user-centred delivery approaches further impeded PrEP scale-up in SSA [ 17 , 28 ]. Evidence-based interventions are urgently required to improve the PrEP care continuum among FSWs in SSA. However, there has been only limited review of the existing literature synthesizing factors affecting the care continuum in the target population globally [ 29 , 30 ], and even less in the context of SSA specifically [ 31 ] in order to suggest such interventions. As research related to the stages of the relatively recently established PrEP cascade may also be considered emerging, the available reviews lack currency and hence involve a limited number of primary studies. Moreover, none of the reviews comprehensively assessed the entire cascade of care, with some purely focused either on quantitative [ 31 ] or narrative aspects of findings [ 29 ]. Our review aimed to make both quantitative synthesis and qualitative exploration of available evidence on determinants of each component of the PrEP cascade among FSWs in SSA. Methods The review has been reported based on the updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement [ 32 ] (see Additional file 1) and registered in International Prospective Register of Systematic Reviews (PROSPERO; Number: CRD420250650765) [ 33 ] (see Additional file 2). Eligibility criteria Studies Observational studies conducted in one or more countries in SSA were eligible for inclusion in the quantitative synthesis without restrictions based on type of design; whereas qualitative studies exploring barriers to and facilitators of PrEP care cascade components were included in the qualitative synthesis. While no restriction was made based on year of publication, quantitative studies focused on evaluating the effects of interventions and qualitative studies exploring FSWs’ experience regarding these were excluded. Our review was also restricted to studies published in English language with full texts available and/or accessible. Population Women aged 18 years or above who engaged in sex work (i.e., selling sex in exchange for money or other valuable material) in the last month of the study commencement. Studies particularly focusing on sub-groups of the population of interest (e.g., FSWs who use drugs) were excluded due to possible unique vulnerability to risk behaviour that may not be generalizable to others. Exposure Various levels of factors including structural, social and behavioural characteristics influencing any of the components of the care cascade. Comparator While the absence of a certain exposure characteristic was considered as a comparator for synthesis of evidence, studies were not excluded from the review whether they made comparisons or not. Outcomes Any of the components of the PrEP care cascade (i.e., awareness, acceptability, uptake, adherence or retention in care) without restricting inclusion based on measurement methods. Information sources The primary author (TGF) undertook searches on 12 June 2024 on four bibliographic databases including Medline through Ovid and PubMed for non-Medline articles, and CINAHL and Web of Science through EBSCOhost and Clarivate respectively. He searched the grey literature through Google Scholar on 23 December 2024 and, selected and screened the first 100 results on title. TGF also manually examined reference lists of systematic reviews conducted on a similar topic as well as of studies included in the current review to identify additional studies. We set up email alerts to track on an on-going basis relevant articles indexed by the databases. Search strategy TGF, who has a prior database search experience developed a search strategy based on concepts of “factors” AND “pre-exposure prophylaxis” AND “female sex workers”. Search terms related to these concepts were identified by reviewing the titles and abstracts of five known relevant studies and a draft search strategy was constructed using the initial terms. The strategy identified all five studies when tested on Medline. To align with the eligibility criteria, the search strategy was limited to English-language studies and to those conducted on women. We used the search string “pre-exposure prophylaxis” AND “female sex workers” to conduct a search on Google Scholar. The full search strategy for all databases is provided in the additional file (see Additional file 3). Selection process Results of the search were first checked for duplicates using EndNote’s duplicate identification function and then searched manually to identify and delete those not detected by the function. TGF conducted initial screening of titles and abstracts of the remaining articles to identify potentially eligible studies and to further assess available full text against the eligibility criteria. Excluded articles were verified by one of the co-authors (TLE) and disagreements between the reviewers were resolved by consensus. Data collection process : Data were extracted using a checklist adapted from the Cochrane Checklist for Data Collection [ 34 ] (see Additional file 4). The checklist captured information related to characteristics of the studies including: authors, year of publication, country, participants, methods and designs used, outcomes assessed and measurement instruments, and the main findings of the study. The primary author (TGF) undertook data collection from the included studies which was then checked by TLE for any errors, with disagreements being resolved through discussion. Data items The eligible outcomes were awareness of PrEP (often referred to as “ever heard of”), acceptability (“willingness to use”), uptake (“ever use”), adherence (“compliance to dose”) and retention in care (“attending a follow-up visit”) at a given timeframe. All results that were compatible with each outcome definition from each study were sought with no restrictions on time points or measurements. Study risk of bias assessment : We used the Cochrane “Risk of bias” tool for non-randomised studies – of exposure (ROBINS-E) to assess risk of bias in the included studies [ 35 ] (see Additional file 5). The tool begins with three items – authors’ attempt to control confounders, appropriateness of methods used to measure exposure and outcomes. This informs the decision whether to proceed with further assessment with failure to meet any of the requirements indicating a “very high risk of bias” and requires no further assessment. The main part of the tool contains seven domains of bias: i) bias due to confounding; ii) bias arising from measurement of the exposure; iii) bias in selection of participants; iv) bias due to post-exposure intervention; v) bias due to missing data; vi) bias arising from measurement of the outcome; and vii) bias in selection of reported results. Each domain was addressed by answering a series of signalling questions with response options: ‘Yes’, ‘Probably Yes’, ‘Probably No’, ‘No’ and ‘No information’. Judgements on the risk of bias arising from each domain made (as “Low risk of bias”, “Some concerns”, “High risk of bias” and “Very high risk of bias”) using an inbuilt algorithm based on responses to the signalling questions. Finally, an overall judgement was made based on domain-level judgements using an algorithm given for this purpose. The methodological quality of included qualitative studies was assessed using the JBI Critical Appraisal Checklist for Qualitative Research [ 36 ] (see Additional file 6). The checklist mainly addresses quality issues related to congruity between the philosophical perspective, methodology, research question, data collection methods, and analysis and interpretation. It also raises questions concerning the researcher’s cultural and theoretical influence on the research, representation of participants and their voices and whether the study has an ethical approval from an appropriate body. Both quantitative and qualitative studies were initially assessed for risk of bias by the primary author (TFG) and then the results were checked by the co-author (TLE) with discrepancies resolved by discussion. Data synthesis Variation (methodological heterogeneity) among studies in assessing types of exposures, especially among those investigating “uptake” and/or “acceptability” (although the outcomes were generally assessed in a similar way), and in measuring adherence and retention in care, precluded conducting any statistical synthesis of quantitative results. Therefore, we provided a narrative synthesis of both quantitative and qualitative results and integrated the findings in the discussion section for interpretation. Results Study selection Our search identified 856 records from the bibliographical databases (including two records obtained from email alerts). After duplicate removal, 588 records were screened, of which 501 were excluded based on title and/or abstract review. A further 48 records were identified in Google Scholar (25), and by reviewing the reference lists of previous relevant systematic reviews and of the included studies (23). Of 128 reports sought for retrieval from all sources, 68 were retrieved for eligibility assessment and 53 reports were finally included in the review as depicted in the PRISMA flow diagram below (see Fig. 1). Three studies [ 37 – 39 ] were found to be potentially relevant for which full text was not accessible. Figure 1: PRISMA flow diagram showing study selection process Study characteristics The majority (43 of 53) of studies were obtained from eastern and southern parts of SSA. Accordingly, eight studies were conducted in Uganda [ 16 , 40 – 46 ], seven in South Africa [ 23 , 25 , 47 – 51 ], six in Ethiopia [ 7 , 52 – 56 ], another six in Rwanda [ 57 – 62 ] and five in Tanzania [ 21 , 63 – 66 ]. While Kenya [ 67 – 70 ] and Zimbabwe [ 22 , 71 – 73 ] each contributed four studies, Zambia [ 74 , 75 ], Nigeria [ 76 , 77 ], Malawi [ 78 , 79 ] and Benin [ 80 , 81 ] had two studies each. The remaining five studies were conducted in Botswana [ 82 ], Ghana [ 83 ], Senegal [ 84 ], Cameroon [ 85 ] and the Democratic Republic of Congo [ 86 ]. The main characteristics of quantitative studies included in the review are presented in Table 1 . Of 35 studies, most (25) employed a cross-sectional design [ 16 , 21 , 23 , 40 , 41 , 43 , 44 , 52 – 56 , 58 – 60 , 64 , 66 , 68 , 73 , 76 – 78 , 82 , 83 , 86 ] and ten used a follow-up design - five prospective [ 65 , 80 , 81 , 84 , 85 ] and the other five retrospective designs [ 45 , 48 , 49 , 57 , 61 ]. Three studies [ 22 , 63 , 69 ] used a mixed-methods approach with all using a cross-sectional design for their quantitative component. Table 1 Characteristics of quantitative studies assessing PrEP care continuum among female sex workers in sub-Saharan Africa Author Year Country Population Design Exposure PrEP outcome assessed Outcome measurement Results and conclusions **Beckham et al. [ 67 ] 2022 Tanzania 293 FSWs Cross-sectional -Perceived HIV risk -Social support a) Awareness b) Acceptability a) Ever heard of PrEP (yes/no) b) Thinking PrEP is worth taking (yes/no) Awareness 8%; acceptability 58% *Acceptability independently associated with having STI symptoms in the past six months (AOR 2.52; 95%CI: 1.38–4.62) and higher social cohesion (AOR 2.12; 95%CI: 1.29–3.50) Chimbindi et al. [ 24 ] 2022 South Africa 194 young (18-24yrs old) FSWs Cross-sectional --- a) Awareness b) Uptake a) Ever heard of PrEP (yes/no) b) Ever use (yes/no) Awareness 11%; uptake 0% *No analyses performed Churu et al. [ 68 ] 2023 Tanzania 360 FSWs on PrEP Cross-sectional -Perception of PrEP -Attitude towards PrEP service delivery -Social support Adherence -Pill count indicating > 95% use in the last month -Self-report on daily use in the last month indicating > 95% use Adherence 48.3% based on pill count and 43.3% based on self-report * Pill count adherence significantly associated with living with family members compared to friends (AOR 2.32; 95%CI: 1.27–4.23); favorable approval towards current pill packaging (AOR 2.43; 95%CI: 1.41–4.19); and having a positive perception of PrEP (AOR 1.71; 95%CI: 1.01–2.91) Faini et al. [ 69 ] 2023 Tanzania -700 FSWs for awareness -231FSWs for acceptability -469 FSWs for current use Cross-sectional Perceived HIV risk a) Awareness b) Acceptability c) Current use a) Ever heard of PrEP (yes/no) b) Willingness to use (yes/no) c) Being on PrEP (yes/no) Awareness 67%; acceptability 98%; current use 8% *Current use significantly associated with having a long-term partner (AOR 4.19; 95% CI: 1.44–12.18); and having sex with an HIV-infected partner in the last three months (AOR 3.98; 95% CI: 1.20- 13.15) Guure et al. [ 88 ] 2022 Ghana -5107 FSWs for acceptability -998 FSWs for uptake Cross-sectional -PrEP awareness -Perceived HIV risk a) Acceptability b) Uptake a) Willingness to use (yes/no) b) Ever use (yes/no) Acceptability 53.6%; uptake 6.4% *Acceptability positively associated with PrEP awareness (AOR 2.59; 95%CI: 2.22–2.98); entry into sex work at age < 25yrs compared to those 25 to 34yrs (AOR 0.84; 95%CI: 0.72–0.95); having been in a long-term relationship (AOR 1.52; 95%CI: 1.09–2.01); having been screened for STI (AOR 1.23; 95%CI: 1.10–1.40); and injecting drug use (AOR 5.31; 95%CI: 1.64–10.60) *Uptake significantly associated with having been screened for STI (AOR 5.2; 95%CI: 1.68–11.36) **Hensen et al. [ 23 ] 2021 Zimbabwe 538 young (18-24yrs old) FSWs Cross-sectional -Perceived HIV risk -Social support a) Awareness b) Uptake a) Ever heard of PrEP (yes/no) b) Ever use (yes/no) Awareness 96%; uptake 34% *Uptake significantly associated with reporting more (10+) clients in the past month (AOR 1.71; 95%CI: 1.06–2.76); duration (2–3 years) of selling sex compared to lesser duration (AOR 0.51; 95%CI: 0.32–0.83); positive perception of peer support to PrEP use compared to negative perception (AOR 0.54; 95% CI: 0.31–0.95) and visiting female sex worker program (AOR 2.92; 95%CI: 1.91–4.46) Leis et al. [ 73 ] 2021 Kenya -215 FSWs for magnitude of uptake and current use -160 FSWs for final analysis of current use Cross-sectional Client-perpetrated violence a) Uptake b) Current use a) Ever use (yes/no) b) Being on PrEP (yes/no) Uptake 61%; current use 46.5% *While recent client-perpetrated emotional violence associated with decreased current use (AOR 0.23; 95%CI: 0.07–0.71), client-perpetrated physical violence associated with increased current use (AOR 3.01; 95%CI: 1.16–7.81)) Lichtwarck et al. [ 70 ] 2023 Tanzania 470 FSWs Prospecti-ve Follow- up -Mental distress -Perceived HIV risk Retention in care Presenting for 56 days follow-up visit Retention in care 25.4% *While mental distress was associated with increased risk of disengagement (ARR 1.14; 95%CI: 1.01–1.27), having higher number of clients (≥ 30) per month associated with lower risk (ARR 0.80; 95% CI: 0.68–0.91) **Litiema et al. [ 74 ] 2021 Kenya 345 FSWs on PrEP Cross-sectional Behavioural factors Adherence -Self-report on daily use in the last month -Pharmacy refill Self-reported adherence 61%; refill adherence 67% *Considering to stop PrEP (AOR 3.86; 95%CI: 2.11–7.06 ) and use of reminder (AOR 1.85; 95%CI: 1.12–3.02) positively associated with self-reported adherence Shibesh et al. [ 56 ] 2023 Ethiopia 334 FSWs Cross-sectional -Perceived HIV risk -Social support a) Awareness b) Uptake a) Ever heard of PrEP (yes/no) b) Ever use (yes/no) Awareness 27.3%; uptake 15.9% *While death of either parent (only father alive: AOR 0.23, 95%CI: 0.02–0.64; only mother alive: AOR 0.31; 95% CI: 0.02–0.74) and being single (AOR 0.27; 95% CI: 0.06–0.94) negatively associated with PrEP uptake, having a history of STI positively associated (AOR 2.82; 95%CI: 1.60–4.77) Sarr et al. [ 89 ] 2020 Senegal 267 FSWs Prospective follow up Sociodemo-graphic factors a) Uptake b) Adherence c)Retention in care a) Initiated on PrEP b) -Electronic monitoring (EM) of each opening of the pill container -Blood TFV level of > 35.5 ng/ml, consistent with daily dosing of Truvada in a week c) Making consecutive quarterly clinic visits -Uptake 82.4% -EM adherence 80% at 1st month, 50% 2nd month; blood drug level adherence 42.6% at 3rd month, 21.7% at 6th month -Retention in care 79.9% at 6th month, 73.4% at 12th month *No sociodemogrphic factors associated with retention in care Rao et al. [ 52 ] 2022 South Africa 2776 FSWs Retrospective follow up Sociodemo-graphic factors a) Uptake b) Retention in care a) Initiation on PrEP b) Attending a monthly appointment Uptake 27.5%; retention in care at 1st month 53%, 33% at 4th month, 18% at 7th month and 9% at 12th month *Younger women (< 25yrs old) less likely to be retained in care (SHR 0.82; 95%CI: 0.76–0.88) Rao et al. [ 53 ] 2023 South Africa 12,581 FSWs Retrospective follow up --- a) Uptake b) Retention in care c) Re-initiation a) Initiation on PrEP b) Making monthly visits c) Restarting after a ≥ 2 months gap Uptake 19%; retention in care at 1st month 41%; re-initiation 9% *No analyses made Ndenkeh et al. [ 90 ] 2022 Cameroon 13,738 FSWs Prospective follow up --- a) Uptake b) Retention in care a) Initiating on PrEP b) Drug refill at 12th month of initiation Uptake 61%; retention in care at 12th month 5% *No analyses performed Nalukwago et al. [ 43 ] 2021 Uganda 126 FSWs Cross-sectional Behavioural factors Adherence Self-report on taking at least six out of seven doses in a week Adherence 71. 4%; *Using long-term contraceptives (AOR 0.06; 95%CI: 0.04–0.77) and not using condoms with clients (AOR 0.07; 95%CI: 0.01–0.42) negatively associated with adherence Nakiganda et al. [ 44 ] 2022 Uganda 524 FSWs on PrEP Cross-sectional Perceived HIV risk Adherence -A pill count of ≥ 85% in the last 3 months -Self-report on taking every day in the last 3 months Pill count adherence 71%; self-report adherence 50.4% *Pill count adherence positively associated with age ≥ 35yrs (AOR 2.40; 95%CI: 1.17–4.86), having an STI in last 3 months (AOR 1.64; 95%CI: 1.07–2.49) and having ≥ 100 sexual partners within 3 months (AOR 2.56; 95%CI: 1.37–4.73), but negatively associated with an intention to use only when felt at risk (AOR 0.26; 95%CI: 0.15–0.43) Mboup et al. [ 85 ] 2021 Benin 255 FSWs Prospective follow up Behavioural factors Adherence TFV blood concentration ≥ 35.5 ng/mL, consistent with taking all 7 pills in a week Overall adherence (i.e., 14days, 6, 12, 18 and 24 months adherence combined) 34.1% *Age (25-34yrs: AOR 2.41; 95%CI: 1.01–5.74; 35-44yrs: AOR 4.38; 95%CI: 1.79–10.75; ≥45yrs: AOR 3.70; 95%CI:1.32–10.35 compared to < 25yrs), duration of follow-up (at 6th month: AOR 0.33; 95%CI: 0.21–0.52; 12th month: AOR 0.24; 95%CI: 0.14–0.42; 18th month: AOR 0.22; 95%CI: 0.12–0.42; 24th month: AOR 0.11; 95%CI: 0.04–0.28 compared to day 14) and intention to adhere (AOR 2.65, 95%CI:1.46–4.81) associated with adherence Martin et al. [ 71 ] 2023 Tanzania 428 FSWs Cross-sectional Sociodemo-graphic factors -Perceived HIV risk a) Uptake b) Current use a) Ever use (yes/no) b) Being on PrEP (yes/no) Uptake 54.7%; current use 53% *Uptake associated with having three or more children (AOR 2.14; 95%CI: 1.08–4.25) and positive attitude towards PrEP (AOR 2.83; 95%CI: 1.75–4.57) Franks et al. [ 91 ] 2022 DRC 352 FSWs Cross-sectional --- a) Uptake b) Retention in care a) Initiation on PrEP b) Attending clinic appointments Uptake 78.7%; retention in care 62.1% at 1st month *No analyses performed Lancaster et al. [ 83 ] 2019 Malawi 150 FSWs Cross-sectional --- a) Awareness b) Acceptability a) Ever heard of PrEP (yes/no) b) Willingness to use (yes/no) Awareness 21%; acceptability 96% *No analyses performed Mboup et al. [ 86 ] 2018 Benin 256 FSWs Prospective follow up --- Adherence Self-report on daily use in the last month Adherence 78% at day 14; 43.3% at 24th month *No analyses performed Mudzviti and Dhliwayo [ 78 ] 2020 Zimbabwe 131 FSWs Cross-sectional -PrEP knowledge -Perceived HIV risk a) Awareness b) Knowledge c) Acceptability d) Likelihood of use a) Ever heard of PrEP (yes/no) b) Estimated using relative importance index (RII > 0.5) c) Willingness to use (yes/no) d) Estimated using relative importance index (RII: range 0–1) Awareness 54%; knowledge 35% of those aware; acceptability 78% of the total; median RII score of the likelihood of use 0.89 *Increase in age (R 2 = 0.0033, p 0.038), having unprotected sex in the last 3-months (R 2 = 0.0448, p 0.026), having good knowledge about PrEP (r = 0.21, p = 0.0153) and decrease in barriers (r = 0.23, p = 0.0074) associated with the increase in the likelihood of use Witte et al. [ 46 ] 2022 Uganda -273 FSWs for Acceptability -283 for Initiation Cross-sectional -Social support -Social stigma a) Acceptability b) Uptake a) Willingness to use (yes/no) b) Initiation on PrEP Acceptability 91%; uptake 55% *-Acceptability negatively associated with more (≥ 5) years in sex work (AOR 0.18; 95% CI: 0.05–0.066) and positively associated with greater perceived social support from family (AOR 1.39; 95% CI: 1.03–1.88) -Uptake negatively associated with greater perceived social support from friends (AOR 0.81; 95%CI: 0.68 − 0.97) and positively associated with a higher perceived stigma due to sex work among family members (AOR 2.20; 95%CI:1.15 − 4.22) Ademe et al. [ 57 ] 2023 Ethiopia 396FSWs Cross-sectional Sociodemo-graphic and behavioural factors a) Knowledge b) Current use a) A score of ≥ 50% on 11-item PrEP knowledge scale b) Being on PrEP (yes/no) Knowledge 51%; current use 46.2% *While being older aged (26–36 years compared to 18–21 years: AOR 0.20; 95%CI: 0.17–0.84) and longer duration of engagement in sex work (3–5 years compared to < 3 years: AOR 0.25; 95%CI: 0.24–0.82) negatively associated with current use, attending secondary and above education (AOR 2.18; 95%CI: 1.05–4.53) and having a good knowledge about PrEP (AOR 4.98;95%CI: 3.90–10.65) positively associated Berhe et al. [ 58 ] 2024 Ethiopia 358FSWs Cross-sectional Sociodemo-graphic, behavioural and structural factors a) Awareness b) Acceptability a) Ever heard of (yes/no) b) Willingness to use (yes/no) Awareness 82%; acceptability 67.9% *Knowledge about PrEP (AOR 3.27; 95%CI: 1.30–8.23) and perceived ease of access (AOR 3.79; 95%CI: 1.50–9.56) associated with acceptability Bongomin et al. [ 47 ] 2023 Uganda 273FSWs Cross-sectional Sociodemo-graphic and behavioural factors Adherence Self-report on daily use in the past 3-months (yes/no) Adherence 66.3% *Having source of income other than sex-work (AOR 3.7; 95%CI:2.11–6.35), undertaking sex-work both in urban and rural setting (AOR 2.5; 95%CI: 1.49–4.35), experience of depression (AOR 3.3; 95%CI: 1.43–7.74) and of post-exposure prophylaxis use (AOR 2.46; 95%CI:1.61–3.77) positively associated with adherence Hussein et al. [ 59 ] 2024 Ethiopia 422FSWs Cross-sectional Sociodemo-graphic and behavioural factors a) Awareness b) Acceptability a) Ever heard of (yes/no) b) Willingness to use score of greater than a mean value on a 5-point response scale Awareness 22.5%; acceptability 68% *While younger age (18–23 years: AOR 2.9; 95%CI: 1.2–7.4) and being aware of PrEP (AOR 3.9; 95%CI: 1.9–7.96) associated with a higher likelihood of acceptability, lower educational status (AOR 0.36; 95%CI: 0.2– 0.6) associated with lower likelihood of acceptability Mubezi et al. [ 61 ] 2023 Rwanda 268FSWs Retrospective follow up Sociodemo-graphic and behavioural factors Retention in care Attending monthly and then three-monthly scheduled visits Retention in care 81% at 1st month, 67% and 53% at 6th and 12th month respectively *While a desire to have more (≥ 2) children (AHR 1.65; 95%CI: 1.01–2.71) and use of hormonal methods of contraception (AHR 2.09; 95%CI:1.18–3.70) or non-use (AHR 2.04; 95%CI: 1.01–4.12) compared to condom increased the chance of retention in care, seldom (AHR 0.41; 95%CI: 0.228–0.749) or non-use of condom during sex (AHR 0.33; 95%CI: 0.15–0.73) and urban residence (AHR 0.29; 95%CI: 0.18–0.46) decreased the chance of retention in care Naluwogo and Kansiime [ 48 ] 2023 Uganda 124FSWs Cross-sectional --- Uptake Ever use of PrEP (yes/no) Uptake 61.3% *No analysis performed Nwagbo et al. [ 81 ] 2023 Nigeria 260FSWs Cross-sectional --- a) Awareness b) Acceptability c) Uptake a) Ever heard of (yes/no) b) Willingness to use score of greater than a mean value on a 5-point response scale c) Ever use (yes/no) Awareness 31.2%; acceptability 91%; uptake 3.9% *No analysis performed Nzungize and Munyaneza [ 62 ] 2024 Rwanda 333FSWs Cross-sectional Behavioural factors a) Awareness b) Acceptability a) Ever heard of (yes/no) b) Willingness to use (yes/no) Awareness 81%; acceptability 80% *History of STI screening in the last 12-months compared to having no history (AOR 0.28; 95%CI:0.12–0.62) and perception of PrEP benefits compared to no perception (AOR 0.06; 95%CI: 0.16–0.29) associated with acceptability Omo-Emmanuel et al. [ 82 ] 2023 Nigeria 344FSWs Cross-sectional Sociodemo-graphic and behavioural factors a) Awareness b) Acceptability c) Uptake a) Correctly answering 2 out of 3 PrEP knowledge questions b) A score of > 75% on willing to use questions c) Ever use (ye/no) Awareness 76.5%; acceptability 8.1%; uptake 42.4% *-Awareness associated with younger age ( 11) weekly number) of clients compared to less (AOR 0.13; 95%CI: 0.03–0.56), more number of weekly new clients (AOR 3.53; 95%CI: 1.05–11.82) and condom non-use during sex compared to use (AOR 0.75; 95%CI: 0.60–5.13) Umulisa et al. [ 63 ] 2024 Rwanda 273FSWs Cross-sectional --- Current use Being on PrEP (yes/no) Current use 60.4% *No analysis performed Wanyama et al. [ 49 ] 2022 Uganda 350FSWs Retrospective follow up Behavioural and structural factors Retention in care Attending first month clinic visit since PrEP initiation Retention in care 32.3% *Perceived good treatment by PrEP provider increased the likelihood of retention in care (AIRR 1.23; 95%CI: 1.05–1.44] while enacted social stigma decreased the likelihood (AIRR 0.9; 95%CI: 0.814–0.996) Rugira E et al. [ 64 ] 2023 Rwanda 4824FSWs Cross-sectional --- Uptake Ever engaged in PrEP (record review) Uptake 45.6% *No analysis performed Tiro et al. [ 87 ] 2023 Botswana -1254 for uptake -207FSWs for adherence and retention in care Cross-sectional a) Uptake b) Adherence c) Retention in care a) Ever engaged in PrEP (record review) b) Drug refill (record review) c) Retention in care for ≥ 6 months or until the risk period is over (record review) Uptake 16.5%; adherence 72.9%; retention in care 16.9% *While employed FSWs more likely to adhere (AOR 2.36; 95%CI: 1.04–5.57, younger FSWs (18–29 years old: AOR 0.12; 95%CI: 0.03–0.41) less likely to be retained Munyaneza et al. [ 65 ] 2024 Rwanda -1343FSWs -996 FSWs for final analysis of retention in care Retrospective follow up Sociodemo-graphic and behavioural factors a) Awareness b) Acceptability c) Retention in care a) Ever heard of (yes/no-record review) b) Willingness to use (yes/no-record review) c) Attending scheduled appointments (record review) Awareness 62%; acceptability 93%; retention in care at 1st month 92%, 90% at 3rd month, 86% at 6th month 78% at 9th month and 76% at 12th month *While living with someone decreased the likelihood of first month retention in care (AOR 0.59; 95%CI: 0.35–0.99), being employed (AOR 2.36; 95%CI: 1.28–4.32) and perception of HIV risk due to sex work increased the likelihood (both 1st and 12th month retention) compared to a lack of risk perception (1st month: AOR 0.11; 95%CI: 0.04–0.29; 12th month: AOR 0.35; 95%CI: 0.12–0.96) Asmare et al. [ 60 ] 2024 Ethiopia 549FSWs Cross-sectional Sociodemo-graphic and behavioural factors a) Uptake b) Current use a) Ever use (yes/no) b) Being on PrEP (yes/no) Uptake 33.3%; current use 28.8% *While attending higher education (college and above: measure of association (β) 0.89; 95%CI: 0.52–1.08) and knowledge about PrEP (β 1.94; 95%CI: 0.99–2.89) had a positive total (direct and indirect) effect on current use being mediated by PrEP knowledge and attitude respectively, engagement in sex work for longer period (3–5 years: β 0.53; 95%CI: 0.06–1.01) had a direct positive effect AHR: Adjusted hazard ratio; AIRR: Adjusted incidence rate ratio; AOR: Adjusted odds ratio; CI: Confidence interval; DRC: Democratic Republic of Congo; FSWs: Female sex workers; PrEP: Pre-exposure prophylaxis; SHR: sub-Hazard ratio; STI: Sexually transmitted infections: TFV: Tenofovir *R 2 is the extent to which dependent variable can be predicted by predictor variables *r is a correlation between independent and dependent variables ** Represents a quantitative arm of a mixed-methods study The main characteristics of qualitative studies included in the review are shown in Table 2 . Nine of the fifteen studies applied in-depth interviewing (IDI) for data collection [ 7 , 42 , 46 , 47 , 62 , 67 , 70 – 72 ], three undertook focus-group discussion (FGD) [ 25 , 75 , 79 ] and a further three used both techniques [ 50 , 51 , 74 ]. The three mixed-methods studies applied IDI [ 22 ] and both IDI and FGD [ 63 , 69 ] for their qualitative components. Table 2 Characteristics of qualitative studies exploring PrEP care continuum among female sex workers in sub-Saharan Africa Author Year Country Population Data collection technique PrEP outcome assessed Definition of the outcome Findings Amogne et al. [ 7 ] 2022 Ethiopia 17FSWs on PrEP and not initiated IDI a) Uptake b) Adherence a) Initiation on PrEP b) Daily use Barriers to uptake : -Doubts or misconceptions about the effectiveness of PrEP over condoms; uncertainty about how to use condoms and PrEP together -Lack of understanding about the difference between PrEP and ART -Perceived bill burden and side effects Facilitators of uptake : Feeling responsibility for taking care of self and others (e.g., children) Barriers to adherence : Side-effects and pill size; stigma related to HIV; forgetting in relation to the nature of sex work (e.g., day time sleep) Bazzi et al. [ 72 ] 2019 Kenya 45FSWs IDI Acceptability Willingness to use Barriers : -Lack of knowledge/information about PrEP Facilitators : -Perception of being at risk of HIV infection (because of perceived low self-efficacy to consistently use condom which was attributed to partner refusal, condom burst, substance/alcohol abuse, forgetting, high pay, poverty and violence) **Beckham et al. [ 67 ] 2022 Tanzania 10FSWs-IDIs 20FSWs-FGDs IDI and FGD Acceptability Thinking PrEP is worth taking Barriers : Perceived HIV related stigma from clients; perceived pill burden while being healthy Facilitators : Perception of being at risk of HIV infection (e.g., alcohol or other substance abuse) Busza et al. [ 76 ] 2021 Zimbabwe 19FSWs IDI a) Uptake b) Adherence c) Retention in care a) Ever use b) Daily use c) Attending health facility visits to collect drugs Facilitators of uptake : -Information from health care provider and peers Facilitators of adherence : - The use of individual strategies as medication reminders (e.g., linking to daily events such as tooth brushing); and peer support Barriers to retention in care : -Early experience of side-effects -Frequent health facility visits during the earlier phases Eakle et al. [ 51 ] 2019 South Africa 18FSWs IDI a) Uptake b) Adherence a) Ever use b) Daily use Barriers to uptake : -Lack of awareness of PrEP due to its novelty -Disbelief in PrEP efficacy Facilitators of uptake : -Being responsible for family and oneself (i.e., desire to remain healthy, safe, happy and hopeful) -Perceived risk of becoming infected (related to violence, intentional (by clients)/unintentional condom breakage and long-term romantic/sexual relationship) Facilitators of adherence : -Subsequent negative HIV test results -Use of personal strategies as reminder for pill taking (e.g., setting alarms, linking with daily routines, etc.) -Peer/family support; friendly health staff Eakle et al. [ 26 ] 2018 South Africa 69FSWs FGD a) Uptake b) Adherence a) Ever use b) Daily use Barriers to uptake : -Low awareness of PrEP -Perceived side-effects; not being sick Facilitators of uptake : -Perception of being at risk of HIV infection (related to condom burst, client refusal, violence, condomless sex with a main partner in the face of risky behaviour) - Supportive/non-judgmental, flexible and tailored services; social support Barriers to adherence : - Forgetting due to substance/alcohol abuse Facilitators of adherence : -Aligning pill taking with daily routines **Hensen et al. [ 23 ] 2021 Zimbabwe 43 young (18-24yrs old) FSWs IDI a)Uptake b) Retention in care a) Ever use b) Attending health facility visits to collect drugs Barriers to uptake : fear of disclosing sex work; HIV/ART-related stigma; lack of support and opportunity cost of accessing Barriers to retention in care : side-effects; demanding nature of daily pill taking while being healthy; lack of family support due to misconception of PrEP with ART; perceived low HIV risk **Litiema et al. [ 74 ] 2021 Kenya 25FSWs on PrEP IDI and FGD Adherence Dose or refill adherence Barriers : stigma related to PrEP/HIV; substance/alcohol abuse; daily pill taking; nature of work (e.g., mobility); limited counselling on side-effects; limited peer/partner support Stoebenau et al. [ 79 ] 2024 Zambia -25FSWs -10Stakeholders IDIs and FGD a) Uptake b) Continuous use a) Ever use b) Persistence on PrEP Barriers to uptake : -Anticipated drug side-effects as influenced by significant others -The amplifying effects of confusing PrEP for ART (due to limited understanding among clients, social networks and society) which was rooted in HIV stigma Barriers to continuous use : -Experience of drug side-effects -Excessive alcohol use; nature of sex work (e.g., mobility); forgetting; having to take a pill every day - Health system related barriers such as long queues; clinic hours conflicting with work schedules Facilitators of uptake and continuous use : -Perceived HIV risk related to constrained self-capacity to use condoms due to alcohol use or pressure/more money/violence from clients - Accountability and desire to protect family - The presence of social support and welcoming/non-judgmental, convenient, and confidential (community-based) PrEP services Nhamo et al. [ 77 ] 2022 Zimbabwe 20 FSWs IDI Uptake Initiation on PrEP Motivating factors for uptake : - Perceived HIV risk related to condom burst or client refusal to use, partner/client violence or needing more money; being uncertain of clients HIV status - Unexpected HIV negative results (due to risky sexual behaviour) during initiation - Positive encouragement from others (such as peers, friends and family members) -Family responsibility (e.g., taking care of children) Mujugira et al. [ 45 ] 2021 Uganda 21 FSWs IDI Uptake Ever use Facilitators of uptake : -A need for more money as a result of condomless sex -Long-term relationship/partnership Barrier to uptake : Stigma related to PrEP being an ART drug Makhakhe et al. [ 54 ] 2022 South Africa 38 total participants -11 peer educators -26 FSWs -1 Counsellor IDI and FGD Uptake Ever use Motivators of uptake : -Perception of sex work as a risk for HIV infection -Having a long-term relationship - Partners/clients refusal of using condoms -Feeling of self and family responsibility -Having future aspirations (e.g., having better job and healthy life) Emily et al. [ 80 ] 2024 Zambia -43 FSWs -36 Sex work managers/Queen mothers FGD a) Uptake b) Adherence a) Ever use b) Daily use Barriers to uptake : -Perceived drug side-effects -Perceived stigma related to ARV/HIV Barriers to adherence : -Nature of work (e.g., mobility) and forgetting -Experience of drug side-effects -Stigma related to ARV/HIV Makhakhe et al. [ 55 ] 2022 South Africa 39 total participants -37 FSWs -2 Health workers IDI and FGD Uptake and continuous use Initiating on PrEP and continue using Barriers to uptake and continuous use : -Low risk perception by new entrants to sex work - Perceived and enacted social stigma by peers, clients and partners related to HIV; as PrEP equated to/misperceived as ARV and this associated with risk of infection due to sex work -Sex work stigma -Limited understanding of PrEP services among health care workers Facilitator of uptake and continuous use : -Perceived HIV risk due to sex work -Understanding PrEP as a self-controlled method -Self-love and love of/feeling responsible for others (e.g., children), and possessing aspirations and goals for the future Restar et al. [ 75 ] 2017 Kenya 21 FSWs IDI Acceptability Willingness to use Barriers to acceptability : Perceived burden of daily use and drug side-effects Facilitators of acceptability : Perceived risk of infection due to a high possibility of unprotected sex; self-care/love Shea et al. [ 84 ] 2019 Malawi 44 FSWs FGD Acceptability Willingness to use Barriers to acceptability : - Perceived drug side-effects; burden of daily use; forgetting due to the nature of sex work (e.g., travel or staying out) -Perceived diminished self-efficacy to consistently use due to excessive drinking -Perceived stigma due to misconception of PrEP as ARVs Facilitators of acceptability : Perceived high risk of infection due to possible unprotected sex (condom break, client refusal to use condom, violence, long-term partnership, and a need for more money from condomless sex); self-love Mpirirwe et al. [ 50 ] 2024 Uganda 19FSWs IDI Accessing PrEP Picking up drugs from PrEP centres Barriers to access : - Limited counselling by providers attributable to limited training - Stigma related to HIV Facilitators of accessing PrEP : Private delivery environment and friendly/non-judgmental providers Ross et al. [ 66 ] 2024 Rwanda 14FSWs IDI a) Awareness b) Uptake c) Continuous use a) Ever heard of (yes/no b) Ever use (yes/no) c) Being on PrEP Barriers to uptake and continuous use : Stigma related to HIV (attributed to confusion between PrEP and ART) and to sex work itself Facilitators of uptake : - Information from health care providers and social networks such as peers, friends, community mobilizers and FSWs associations - Perceived risk of infection (related to possibilities of unprotected sex due to high number of clients, condom refusal, needing better incentive/money because of condomless sex) -Feeling responsible for halting HIV transmission ART: Antiretroviral therapy; ARV: Antiretroviral; FGD: Focus group discuss; FSWs: Female sex workers; IDI: In-depth interview; PrEP; Pre-exposure prophylaxis; ** Represents a qualitative arm of a mixed-methods study Outcomes Twenty-five quantitative [ 16 , 21 – 23 , 48 , 49 , 52 – 56 , 58 , 61 , 63 , 66 , 68 , 73 , 76 – 78 , 82 – 86 ] and nine qualitative studies [ 7 , 22 , 25 , 47 , 51 , 62 , 71 , 74 , 75 ] (including the respective arms of mixed-methods studies) assessed two or more components of the cascade. A total of fourteen quantitative studies [ 21 – 23 , 52 – 55 , 58 , 61 , 63 , 73 , 76 – 78 ] and one qualitative study [ 62 ] investigated awareness or knowledge about PrEP, and twelve quantitative [ 16 , 21 , 54 , 55 , 58 , 61 , 63 , 73 , 76 – 78 , 83 ] and four qualitative studies assessed acceptability [ 63 , 67 , 70 , 79 ]. In addition to six quantitative studies that investigated current (active) use of PrEP [ 21 , 53 , 56 , 59 , 66 , 68 ], eighteen quantitative [ 16 , 22 , 23 , 44 , 48 , 49 , 52 , 56 , 60 , 66 , 68 , 76 , 77 , 82 – 86 ] and twelve qualitative studies [ 7 , 22 , 25 , 42 , 47 , 50 , 51 , 62 , 71 , 72 , 74 , 75 ] assessed uptake. Nine quantitative studies investigated adherence to PrEP [ 40 , 41 , 43 , 64 , 69 , 80 – 82 , 84 ] as did six qualitative studies [ 7 , 25 , 47 , 69 , 71 , 75 ], while three studies examined continuous use [ 51 , 62 , 74 ]. Ten quantitative [ 45 , 48 , 49 , 57 , 61 , 65 , 82 , 84 – 86 ] and two qualitative studies [ 22 , 71 ] assessed retention in care. Measurement All quantitative studies investigating awareness of PrEP ascertained the outcome by asking whether participants “ever heard of” the method with the response provided as “yes” or “no”. One study assessed FSW’s knowledge by estimating the relative importance index of different PrEP knowledge questions [ 73 ] and another based on a score of ≥ 50% using a knowledge assessment scale [ 53 ]. While most studies determined PrEP uptake by asking “ever use” with a “yes” or “no” response, nine studies assessed in terms of newly initiating the prevention method [ 7 , 16 , 48 , 49 , 51 , 72 , 84 – 86 ]. Other nine studies assessed current or continuous use by asking whether participants were on PrEP [ 21 , 51 , 53 , 56 , 59 , 62 , 66 , 68 , 74 ] and one study in terms of accessing PrEP services [ 46 ]. PrEP adherence was measured in a variety of ways at different time points since initiation and duration of use. While two studies assessed using self-report and pill-count on dose adherence irrespective of PrEP initiation time [ 41 , 64 ], four studies used self-report [ 40 , 43 , 69 , 81 ] one supporting this with a monthly pharmacy refill adherence [ 69 ]. One study measured only a monthly pharmacy refill adherence [ 82 ]. Three studies strictly defined self-reported adherence as reporting 100% use of prescribed dose [ 41 , 43 , 81 ] and other two defined as the use of > 95% [ 64 ] and > 85% [ 40 ]. Two studies set pill count adherence at > 95% [ 64 ] and ≥ 85% [ 41 ]. Two studies [ 80 , 84 ] determined blood drug level (both taking ≥ 35.5 ng/mL TFV blood concentration as 100% weekly adherence), one of which additionally applying electronic monitoring of daily use [ 84 ]. Retention in care was assessed by all studies in terms of attending a range of follow-up clinic visits after PrEP initiation. While four studies [ 48 , 57 , 61 , 84 ] measured the outcome at more than one point in time (ranging from first month to twelfth month), six [ 45 , 49 , 65 , 82 , 85 , 86 ] measured at a specific point in time – at first, second, sixth and twelfth month. Risk of bias Using the ROBINS-E, of 27 quantitative studies that performed statistical analyses on association between exposures and outcomes, five were assessed as having low overall risk of bias [ 16 , 21 , 63 , 64 , 66 ] and four had some concerns [ 22 , 54 , 65 , 83 ]. While eight studies had a high risk of bias [ 43 , 55 – 57 , 61 , 68 , 80 , 82 ], ten had a very high risk of bias [ 40 , 45 , 48 , 52 , 53 , 58 , 69 , 73 , 77 , 84 ] with four of these decided without the need for further assessment [ 45 , 48 , 69 , 77 ]. Most studies with the high risk and very high risk of bias were those assessing adherence and retention in care. The risk of bias assessment results are presented in the additional file (see Additional file 7). The majority of included qualitative studies [ 7 , 25 , 42 , 47 , 50 , 51 , 62 , 70 , 74 , 75 , 79 ] addressed more than half of the ten quality domains specified by the JBI appraisal checklist, with one study scoring eight [ 72 ]. Five studies addressed half of the domains [ 22 , 46 , 63 , 67 , 71 ] and one study exploring adherence did not address any [ 69 ]. The details of quality assessment results are presented in the additional file (see Additional file 8). Results of individual studies Quantitative results Awareness, acceptability and uptake The level of PrEP awareness among FSWs ranged from 8% in a study from Tanzania [ 63 ] to 96% in Zambia [ 22 ]. Slightly more than half (53%) of the studies reported an awareness level greater than 50% [ 21 , 22 , 54 , 58 , 61 , 73 , 77 ]. One study reported a PrEP knowledge level of 35% among those who were identified as aware of PrEP [ 73 ] and another found 51% among all participating FSWs [ 53 ]. Among studies that investigated PrEP acceptability, the median ranged between 54% and 80% [ 54 , 55 , 58 , 63 , 73 , 83 ]. The remaining studies reported willingness to use in more than 90% of FSWs [ 16 , 21 , 61 , 76 , 78 ] with the exception of one study from Nigeria which reported just 8% [ 77 ]. Most studies (39%) that investigated PrEP uptake reported ‘ever use’ or recent initiation in more than 50% of FSWs [ 16 , 44 , 66 , 85 , 86 ], with one study reporting 82% [ 84 ]. Notably, the level of uptake was less than 20% in the majority of studies that reported lower than 50% [ 23 , 49 , 52 , 76 , 82 , 83 ]. The proportion of current PrEP users ranged from 8% again in Tanzania [ 21 ] to 60% in Rwanda [ 59 ] with half of the studies reporting between 45% and 53% [ 53 , 66 , 68 ]. Adherence and retention in care The prevalence of PrEP adherence greatly varied depending on precision of methods used for measurement. Studies that directly determined drug concentration in the blood found lower prevalence compared to those using electronic monitoring, self-report or a pill count method. One study reported a composite blood-drug-level adherence of just 34% combining results of fourteenth day as well as sixth, twelfth, eighteenth and twenty-fourth month adherence since PrEP initiation [ 80 ]. Another study using the same method found 42.6% and 21.7% adherence at third and sixth month, respectively [ 84 ]. This same study used an electronic monitoring method and found a sharp decline from 80% at first month to 50% at second month [ 84 ]. First month self-reported adherence, on the other hand, ranged from 43.3–78% [ 64 , 81 ] and showed a declining pattern [ 81 ]. Two studies reported a three-month self-reported adherence of 50% [ 41 ] and 66% [ 43 ] without specifying duration on PrEP while another study reported a one-month adherence of 61% [ 69 ]. Other two studies reported a one-month and three-month pill-count adherence of 48.3% [ 64 ] and 71% [ 41 ], setting adherence cut-off at > 95% and ≥ 85% use of prescription, respectively. Two studies reported a monthly pharmacy-refill adherence of 67% [ 69 ] and 73% [ 82 ] without specifying PrEP duration. Despite some exceptions, rates of retention in care consistently decreased over time following PrEP initiation. For example, one study reported a retention rate of 53% at the first month which declined to 33% at the fourth month and to just 9% at the twelfth month [ 48 ]. Similarly, two other studies reported a sharp drop over time; one reporting a decline from 92% at the first month to 86% at the sixth month and to 76% at the twelfth month [ 61 ] and the other an even steeper drop from 81% at the first month to 67% at the sixth month and to 53% at the twelfth month [ 57 ]. Another study reported that 80% of FSWs who initiated PrEP were retained in care at the sixth month, with 73% remaining at the twelfth month [ 84 ]. Other studies reported rates of retention ranging from 41–62% at the first month [ 49 , 86 ] and as low as just 5% at the twelfth month [ 85 ]. Two studies, one from Uganda [ 45 ] and the other from Botswana [ 82 ], reported considerably low rates of retention at the first (32%) and the sixth month (17%) of PrEP initiation respectively. Factors associated with PrEP cascade components Acceptability and uptake Behavioural characteristics that can increase the risk of HIV-infection were significantly associated with PrEP acceptability and uptake. While ever having been screened for or diagnosed with sexually transmitted infections (STIs) was associated with both acceptability [ 58 , 63 , 83 ] and uptake [ 83 ], an experience of recent unprotected sex, injecting drug use and being in a long-term relationship increased the odds of acceptability [ 73 , 77 , 83 ]. Similarly, FSWs who had more clients and engaged in sex work for longer period were more likely to accept [ 77 ] and initiate [ 22 ] although some contradictions exist regarding the influence of duration of sex work on acceptability [ 16 ]. The likelihood of acceptability [ 16 , 63 ] and uptake [ 22 , 52 ] was also reported to be associated with perceived social support from peers and family despite some contrasting findings regarding support from close friends and uptake [ 16 ]. Although one study uniquely reported a positive association between sex-work stigma from family and PrEP uptake [ 16 ], another study found an increase in the likelihood of acceptability with a decrease in stigma [ 73 ]. FSWs were more likely to accept PrEP when they were well-aware of it and perceived ease of access [ 54 , 55 , 58 , 73 , 83 ], and to initiate when they possessed a positive attitude towards the method [ 66 ]. Increasing age (although some exceptions [ 55 ]) and having more children respectively increased acceptability [ 73 ] and uptake [ 66 ], and entry into sex work at younger age (especially below 25 years) was associated with a higher likelihood of acceptability [ 83 ]. Adherence, current use and retention in care Most factors that were associated with the preceding cascade elements essentially appeared to persist in influencing adherence, current use and retention in care. Accordingly, behavioural characteristics related to HIV risk perception were significantly associated with all the three outcomes. Having a long-term partnership, and sex with an HIV-positive partner were associated with current use [ 21 ]. Having a greater number of clients increased the likelihood of both adherence [ 41 ] and retention in care [ 65 ]; and FSWs were more likely to adhere when they engaged in sex work in more than one location (e.g., both urban and rural settings), experienced STI and used post-exposure prophylaxis (PEP) [ 41 , 43 ], and to continue using when they encountered physical violence and wholly perceived HIV risk due to sex work [ 61 , 68 ]. However, contrasting findings exist regarding the influence of duration of engagement in sex work on current use [ 53 , 56 ]. Attitude towards PrEP and intention to use were two other behavioural constructs reported to influence adherence, which was significantly higher when FSWs had a positive attitude towards PrEP and its packaging [ 64 ] but lower when they lacked an intention to consistently use it [ 41 , 80 ]. On the other hand, while self-efficacy to consistently use condom during sex was also reflected on adherence [ 40 ] and retention in care [ 57 ], PrEP knowledge was linked with continuous use [ 53 ]. Psychological conditions such as mental distress and experience of emotional violence were negatively associated with current use [ 68 ] and retention in care [ 65 ] although one study found a positive association between experience of depression and adherence [ 43 ]. The effect of social factors on PrEP use was reported as quite mixed. While living with a family member rather than a friend significantly enhanced adherence [ 64 ], living with someone at all discouraged retention in care [ 61 ]. Possibly reflecting the latter case, enacted social stigma was significantly associated with reduced retention in care [ 45 ]. As they were to accept and initiate PrEP, older FSWs (> 25 years of age) were also more likely to adhere [ 41 , 80 ] and be retained in care [ 48 , 82 ] despite some exceptions regarding the latter [ 53 , 84 ]. The chance of retention in care was high when FSWs expressed a desire to have more children [ 57 ]. Being engaged in other jobs in addition to sex work and attaining a higher level of education were associated with both increased adherence and retention in care [ 43 , 53 , 56 , 61 , 82 ], and urban residence decreased retention in care [ 57 ]. While use of a reminder to medication schedule was associated with increased adherence [ 69 ], being on a long-term contraceptive was linked with reduced adherence [ 40 ]. Adherence also showed a decreasing pattern as follow-up time increased [ 80 ], but retention in care increased when FSWs perceived good treatment by health care providers [ 45 ]. Qualitative findings Acceptability The most frequent theme emerging from the studies as a barrier to PrEP acceptability was related to perceived pill-burden and drug-side effects, which seemed to be difficult for FSWs to accept while being apparently healthy [ 63 , 70 , 79 ]. As was the case in the quantitative findings, perceptions of social stigma (especially among clients) was the second most common barrier to PrEP acceptability, which was often associated with the similarity between PrEP and ARV drugs [ 63 , 79 ]. That is, FSWs feared that others would assume they were HIV-infected – an already greatly stigmatized condition in SSA. Other reported barriers included a lack of adequate knowledge about PrEP [ 67 ] and perceived low self-efficacy to consistently use due to the mobile nature of sex work and frequent alcohol use [ 79 ]. Featuring prominently in the qualitative studies (also a prominent factor in quantitative studies), was a perceived high HIV risk due to inconsistent condom use that was attributed to various factors including partner/client refusal and violence. Being engaged in a long-term relationship, experience of condom burst, needing more money and/or substance misuse were found to be important facilitators in all studies that explored acceptability [ 63 , 67 , 70 , 79 ]. Similarly, intention to self-care (maintenance of health in the face of risky (sex) work) appeared to facilitate PrEP acceptability [ 70 , 79 ]. Uptake Nearly all of the perceived barriers to and facilitators of PrEP acceptability also appeared to influence the actual uptake. Social stigma (from clients, peers, friends, family and the society at large) related to misconceptions of PrEP as an HIV treatment rather than a prevention method was the most frequently reported barrier to uptake [ 22 , 42 , 51 , 62 , 74 , 75 ]. A related barrier was a general lack of awareness among FSWs about the method [ 7 , 25 , 47 , 71 ]. Some studies reported the existence of doubt among FSWs about how to use PrEP along with condom and its additional benefits [ 7 , 47 ]. Reluctance to initiate PrEP was also due to its use essentially serving as a disclosure of sex work, a practice that is highly stigmatized in many settings [ 22 ]. Another persistent behavioural challenge to the PrEP continuum and uptake was perceived drug side-effects which FSWs often found it difficult to accept while being in a state of complete health [ 7 , 25 , 74 , 75 ]. Structural factors related to the opportunity cost of service access including transportation cost and long waiting times as well as providers’ hesitance to make timely prescriptions (partly attributable to having limited skills) also contributed to low PrEP uptake [ 22 , 51 ]. FSWs tended to be more likely to start PrEP when it was provided in a non-judgmental user-friendly way, often using peers [ 25 , 74 ]. FSW’s perceptions of the high risk of HIV-infection in the face of unsafe sex-work environments enhanced PrEP uptake across included studies [ 25 , 42 , 47 , 50 , 51 , 62 , 72 , 74 ]. Another common facilitator of uptake was that of FSW’s sense of self-care and responsibility for others (e.g., children), as well as having future goals and positive aspirations [ 7 , 47 , 50 , 51 , 62 , 72 , 74 ]. The experience of obtaining a negative HIV test when they did not expect it was a motivating factor for FSWs to initiate PrEP [ 72 ]. FSWs were also motivated to initiate PrEP when they understood that it is a self-controlled prevention method without the need for client approval [ 51 ]. Lack of social support adversely affected uptake [ 22 ], but FSWs were often found to be motivated to initiate when they received support from peers, friends and family as well as community mobilisers [ 25 , 62 , 72 , 74 ]. Adherence and retention in care A prominent theme affecting PrEP adherence in FSWs was forgetting to take the medication, frequently associated with the nature of sex-work (e.g., night work, mobility of sex workplace and substance misuse) [ 7 , 25 , 69 , 74 , 75 ]. Experiences of drug-side effects (especially in the early phase of treatment) and pill-burden were commonly reported as influencing both daily use [ 7 , 69 , 75 ] and continuation [ 22 , 71 , 74 ]. Perceptions of social stigma continued playing a crucial role in the care continuum by reducing FSW’s capacity for daily [ 7 , 69 , 75 ] as well as continuous PrEP use [ 46 , 51 , 62 ]. This was due to the association between PrEP and HIV-infection and sex-work – both of which remain highly stigmatized in SSA society. Social stigma was also associated with reduced social support from peers and family, which was an important facilitator of adherence [ 47 , 69 , 71 ] and retention in care [ 22 , 74 ]. Consistent with the quantitative findings, FSWs were found to be more PrEP compliant when they were able to use individual strategies to manage their medication schedule (e.g., setting alarms and linking medication time with daily routines) [ 25 , 47 , 71 ]. HIV-negative test results subsequent to PrEP initiation tended to motivate FSWs to comply with medication schedules [ 47 ] but they were discouraged to continuously use when they had a perception of low HIV risk [ 22 , 51 , 74 ]. In terms of service delivery, while limited counselling availability, long clinic waiting time and unresponsive work hours discouraged retention [ 46 , 69 , 71 , 74 ], private and non-judgmental delivery models encouraged both initiation and continued PrEP use [ 46 , 74 ]. Discussion Our review aimed to synthesize the evidence for contextual factors affecting PrEP care continuum among FSWs in SSA – a population group bearing a high burden of the epidemic in the region [ 2 ]. Synthesis of such factors facilitates the development of evidence-based interventions that can enhance the scale-up of the programme to increase its impact on the epidemic – as part of a combination prevention approach including biomedical, behavioural and structural interventions for high risk population groups such as FSWs [ 87 ]. There is large variation in the FSW’s level of awareness about PrEP in SSA, which reflects the impact of educational efforts in some settings but highlights gaps in such efforts in other areas. This has also been observed across settings within the same country. A previous global review [ 30 ] similarly reported a wide range of awareness level across countries, which was associated with access to various information sources such as participation in PrEP research, peer associations, social media and other mainstream media. Our review identified a generally high level of PrEP acceptability among FSWs but only moderate uptake, consistent with previous reviews [ 30 , 31 ]. However, considerably low levels of acceptability and uptake have been reported in some settings, and the overall level of current use was lower relative to uptake, suggesting high discontinuation rates. In all included studies, regardless of the measurement methods, adherence to PrEP was found to be lower than the “protection-effective adherence” set by clinical trials (i.e., > 85%) [ 88 ] and showed a sharp decline over time, which is similar to previous review findings [ 30 ]. A similar pattern was observed for retention in care in the majority of studies, although high retention rates were maintained in some settings. While a limited awareness in association with the novelty of the method to some settings critically influenced the care continuum, especially the earlier stages, a number of individual, social and structural level factors were reported by the reviewed studies that affected each component. It emerged from the review that the entire care continuum is highly dependent on FSW’s perception of elevated HIV risk, perceptions formed through experiencing or anticipating unsafe sexual encounters. The association between individual risk perceptions and high uptake, and consistent and continuous use has been reported in previous reviews [ 29 , 30 ]. This suggests the importance of continuous risk assessment and attention to the social drivers of HIV perceived vulnerability within the context of SSA [ 89 ]. This needs to be supported by ongoing HIV testing as negative test results subsequent to PrEP initiation appeared to facilitate the care continuum in our review. HIV self-testing is a highly recommended approach in this regard as it complements existing testing strategies for PrEP and is preferred for convenience, privacy and self-managed care [ 90 ]. The PrEP care continuum among FSWs in SSA is more likely to be effective when the users perceived responsibility for current circumstances and held life aspirations in the future. This was demonstrated by the fact that motivation of health maintenance was driven by the responsibility for a family, or the desire to have a family, and the belief that sex work is only temporary primarily performed because of a lack of alternative livelihood [ 91 ]. This suggests that life skills training may enhance FSW’s capacity to make informed decisions in addition to identification of an individual high risk season to facilitate targeted PrEP use [ 89 ]. Perceived social support from significant others and other close ones including family, peers and friends was found to be critical in enhancing the PrEP care continuum among FSWs. Beyond being an important source of material and emotional help which could reduce mental distress and enhance self-efficacy, such support may also serve as an essential source of information encouraging informed decision making. Correspondingly, perceived social stigma from such close ones as well as the larger society including clients – usually arising from the association between HIV infection and sex work with PrEP – has been identified as an important PrEP care continuum barrier. Community mobilization and engagement in the PrEP programme is strongly suggested to create awareness and hence increase social support while reducing stigma [ 89 , 92 ]. Peer initiatives such as sex-workers programmes are very effective in this regard and should be supported by social marketing of the prevention method [ 30 , 89 , 92 ]. As previous reviews have found [ 29 , 30 , 89 ], there is a high likelihood of improving the PrEP care continuum among FSWs when services are provided in a more accessible and non-judgmental way. As poverty is a major driver of engagement in sex work in the context of SSA [ 91 ], opportunity costs such as transportation to health care facilities and long-waiting times appear to be prominent structural barriers. A previous review in SSA [ 31 ] identified a higher PrEP uptake and lower retention in care when PrEP service was delivered through a health facility-based model compared to community-based model. A hesitancy of providers to prescribe PrEP formed a further structural barrier in our review. This could potentially be attributed to higher priority being given to already infected individuals but may also be due limited skills and knowledge in PrEP, which remains a challenge for facility-based models of service provision in SSA. WHO recommends a differentiated and comprehensive PrEP delivery approach that adapts services to the needs and preferences of the target population [ 90 ]. Health staff training along with engagement of FSWs in service delivery may facilitate a possible combination of different delivery models which are compatible to different contexts [ 89 , 92 ]. Drug side effects and the burden of daily use are proposed by FSWs as barriers to initiating and continuing PrEP use. Although the side effects might be potentially overstated prior to initiation, there have been many reports that PrEP drugs cause temporary discomfort, particularly soon after initiation, which significantly affects adherence and retention in care [ 29 , 30 ]. The frequency of use required for oral PrEP coupled with the absence of disease symptoms (i.e., inherently, PrEP is deployed in those in relatively good health) is a substantial challenge to maintaining the care continuum. Proper counselling of potential side effects and their management methods is suggested especially during initiation. Efforts to ensure the availability of long-acting injectable modalities are also the preferred options by FSWs, as this avoids having to remember doses each day, which can be quite challenging given the highly mobile nature of sex work within the context of SSA [ 5 , 30 ]. Our review findings are limited by the fact that research on PrEP among FSWs in SSA has predominantly concentrated in the eastern and southern part of the region and only few studies have so far been conducted in the central and western countries. Although the former represents a substantial burden of the HIV epidemic among FSWs, the latter also holds high prevalences contributing significantly to the global burden of the disease [ 93 ], and requires further research. Some outcomes such as awareness and acceptability were not assessed in depth by most of the included studies i.e., usually on the basis of ‘Yes’ or ‘No’ response to a single question. This might have led to an overestimate of results overall and is demonstrated by lower estimates reported by studies undertaking more in-depth analysis. Further exploration is required to identify contextual barriers to retention in care as this was undertaken by only a limited number of qualitative studies. Although all included studies defined adherence thresholds as using > 85% of prescribed dose, which is set as a “prevention effective” adherence by clinical trials, variation in the threshold along with the differences in the precision of measurements taken poses a problem in comparing results across studies. That only a third of the included quantitative studies were assessed as having a ‘low risk’ or ‘some concerns’ of bias means that the level of certainty of evidence regarding associations between the exposure variables and outcomes is reduced. This is especially true of adherence and retention in care studies, which account for a large proportion of the ‘very high’ and ‘high risk’ of bias at assessment. However, the consistency of the evidence on the influence of most of the factors identified and the congruence between quantitative and qualitative findings indicates the pervasiveness of the issues in the SSA context and have critical public health implications for policy and practice. Screening of study eligibility, risk of bias assessment and data extraction by a single author might have introduced some error although verification of the results by one of the co-authors reduces the bias. Due to setting-related resource limitations, our search strategy included only four databases and might not have been sufficiently exhaustive to avoid publication bias, and we were unable to access full texts of three potentially eligible studies, although an attempt was made to search for grey literature. The influence of limiting our review to only English studies may also have systematically excluded some studies, although the probability of publication in other languages in SSA is likely to be low as observed in the retrieved records. Conclusions Our findings underscore the importance of adhering to best practices in order to increase awareness about PrEP among FSWs in SSA and to translate the high acceptability into uptake, maintain optimal adherence and retention in care. Continuous risk assessment supported by self-testing and life skills training among FSWs is required to ensure improved PrEP care continuum. At a societal level, community education and engagement efforts are needed to enhance social support and reduce stigma. Finally, the PrEP care continuum can also be improved through implementation of differentiated and user-centred delivery approaches and product modalities. Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials The dataset supporting the conclusions of this article is included within the article and its additional files. Competing interests The authors declare that they have no competing interests. Funding No funding was received for conducting this study. Author contributions TGF developed the search strategy; conducted searching, screening of the articles, data extraction and analysis; drafted the manuscript. ERM undertook subsequent revisions of the manuscript. TLE verified included studies, data extracted, and risk of bias assessment results, and reviewed the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to acknowledge authors of the primary studies. References Kerrigan D, Wirtz A, Baral S, Decke M, Murray L, Poteat T, et al. The global HIV epidemics among sex workers. 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Intimate partner and client-perpetrated violence are associated with reduced HIV pre-exposure prophylaxis (PrEP) uptake, depression and generalized anxiety in a cross-sectional study of female sex workers from Nairobi, Kenya. J Int AIDS Soc. 2021;24 (2):e25711; https://doi.org/10.1002/jia2.25711. Litiema EA, Orago AS, Muia D. Correlates associated with adherence among female sex workers on HIV pre- exposure prophylaxis in Nairobi City County. Journal of Health, Medicine and Nursing. 2021;7(3):29-40; https://doi.org/10.47604/jhmn.1401. Restar AJ, Tocco JU, Mantell JE, Lafort Y, Gichangi P, Masvawure TB, et al. Perspectives on HIV pre- and post-exposure prophylaxes (PrEP and PEP) among female and male sex workers in Mombasa, Kenya: implications for integrating biomedical prevention into sexual health services. AIDS Educ Prev. 2017;29(2):141-53; https://doi.org/10.1521/aeap.2017.29.2.141. Busza J, Phillips AN, Mushati P, Chiyaka T, Magutshwa S, Musemburi S, et al. Understanding early uptake of PrEP by female sex workers in Zimbabwe. AIDS Care. 2021;33(6):729-35; https://doi.org/10.1080/09540121.2020.1832192. Nhamo D, Duma S, Ojewole E, Chibanda D, Cowan F. Factors motivating female sex workers to initiate pre- exposure prophylaxis for HIV prevention in Zimbabwe. PLoS One. 2022;17(7); https://doi.org/10.1371/journal.pone.0264470. Mudzviti T, Dhliwayo A. Perspectives on oral pre-exposure prophylaxis use amongst female sex workers in Harare, Zimbabwe. South Afr J HIV Med. 2020;21(1):1039; https://doi.org/10.4102/sajhivmed.v21i1.1039 Stoebenau K, Muchanga G, Ahmad SS, Bwalya C, Mwale M, Toussaint S, et al. Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis. BMC Public Health. 2024;24(1):1617; https://doi.org/10.1186/s12889-024-19152-y. Emily E, Tendai M, Featherstone M, Mercy LK, Holly MB, Bupe M, et al. Qualitative focus group discussions exploring PrEP method and service delivery preferences among female sex workers and their managers in four Zambian provinces. BMJ Public Health. 2024;2(1):e000483; https://doi.org/10.1136/bmjph-2023-000483. Nwagbo EC, Mmeremikwu AC, Ojide CK. Awareness of and willingness to use pre-exposure prophylaxis to prevent HIV infection among female sex workers in Anambra State, south-eastern Nigeria. Afr J Clin Exper Microbiol. 2023;24(2):168-76; https://doi.org/10.4314/ajcem.v24i2.6. Omo-Emmanuel U, Udah D, Airiagbonbu B, Bwari U, Jegede F, Aka-Okeke C, et al. Assessment of Awareness, Willingness, and Practice of Human Immunodeficiency Virus Pre-Exposure Prophylaxis Among Female Sex Workers in Uyo, Akwa Ibom, Nigeria. TIJPH. 2023;11:28-42; https://doi.org/10.21522/TIJPH.2013.11.04.Art003. Lancaster KE, Lungu T, Bula AK, Shea JM, Shoben AB, Hosseinipour MC, et al. Preferences for Pre-exposure Prophylaxis Service Delivery Among Female Sex Workers in Malawi: A Discrete Choice Experiment. AIDS Behav. 2019;24:1294-303; https://doi.org/10.1007/s10461-019-02705-3. Shea J, Bula A, Dunda W, Hosseinipour MC, Golin CE, Hoffman IF, et al. "The Drug Will Help Protect My Tomorrow": Perceptions of Integrating PrEP into HIV Prevention Behaviors Among Female Sex Workers in Lilongwe, Malawi. AIDS Educ Prev. 2019;31(5):421-32; https://doi.org/10.1521/aeap.2019.31.5.421. Mboup A, Diabaté S, Béhanzin L, Guédou FA, Zannou DM, Kêkê RK, et al. Determinants of HIV Preexposure Prophylaxis Adherence Among Female Sex Workers in a Demonstration Study in Cotonou, Benin: A Study of Behavioral and Demographic Factors. Sex Transm Dis. 2021;48(8):565-71; https://doi.org/10.1097/OLQ.0000000000001373. Mboup A, Béhanzin L, Guédou FA, Geraldo N, Goma-Matsétsé E, Giguère K. Early antiretroviral therapy and daily pre-exposure prophylaxis for HIV prevention among female sex workers in Cotonou, Benin: a prospective observational demonstration study. J Int AIDS Soc. 2018;21(11):e25208; https://doi.org/10.1002/jia2.25208. Tiro M, Mashalla Y, Tapera R, Seloilwe E, Dikobe W. Uptake, Adherence and Retention of Daily Oral Pre-Exposure Prophylaxis among Female Sex Workers in the Greater Gaborone City, Botswana. Int STD Res Rev. 2023:12-24; https://doi.org/10.9734/ISRR/2023/v12i1153. Guure C, Afagbedzi S, Torpey K, Chaurasia A. Willingness to take and ever use of pre-exposure prophylaxis among female sex workers in Ghana. Medicine. 2022;101(5):e28798-e; https://doi.org/10.1097/MD.0000000000028798. Sarr M, Gueye D, Mboup A, Diouf O, Bao MDB, Ndiaye AJ, et al. Uptake, retention, and outcomes in a demonstration project of pre-exposure prophylaxis among female sex workers in public health centers in Senegal. Int J STD AIDS. 2020;31(11):1063-72; https://doi.org/10.1177/0956462420943704. Ndenkeh JJN, Bowring AL, Njindam IM, Folem RD, Fako GCH, Ngueguim FG, et al. HIV Pre-exposure Prophylaxis Uptake and Continuation Among Key Populations in Cameroon: Lessons Learned From the CHAMP Program. J Acquir Immune Defic Syndr (1999). 2022;91(1):39-46; https://doi.org/10.1097/QAI.0000000000003012. Franks J, Teasdale C, Olsen H, Wang C, Mushimebele N, Tenda Mazala R, et al. PrEP for key populations: results from the first PrEP demonstration project in the Democratic Republic of the Congo. AIDS Care. 2022;34(3):359-62; https://doi.org/10.1080/09540121.2021.1969332. Bekker LG, Johnson L, Cowan F, Overs C, Besada D, Hillier S, et al. Combination HIV prevention for female sex workers: what is the evidence? Lancet. 2015;385(9962):72-87; https://doi.org/10.1016/S0140-6736(14)60974-0. Cottrell ML, Yang KH, Prince HM, Sykes C, White N, Malone S, et al. A Translational Pharmacology Approach to Predicting Outcomes of Preexposure Prophylaxis Against HIV in Men and Women Using Tenofovir Disoproxil Fumarate With or Without Emtricitabine. J Infect Dis. 2016;214(1):55-64; https://doi.org/10.1093/infdis/jiw077. Mugo NR, Ngure K, Kiragu M, Irungu E, Kilonzo N. The preexposure prophylaxis revolution; from clinical trials to programmatic implementation. Curr Opin HIV AIDS. 2016;11(1):80-6; https://doi.org/10.1097/COH.0000000000000224. World Health Organization. Differentiated and simplified pre-exposure prophylaxis for HIV prevention: update to WHO implementation guidance. Technical Brief. Geneva, Switzerland WHO; 2022. Scorgie F, Chersich MF, Ntaganira I, Gerbase A, Lule F, Lo YR. Socio-demographic characteristics and behavioral risk factors of female sex workers in sub-saharan Africa: a systematic review. AIDS Behav. 2012;16(4):920-33; https://doi.org/10.1007/s10461-011-9985-z. Pinto RM, Berringer KR, Melendez R, Mmeje O. Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature. AIDS Behav. 2018;22(11):3681-91; https://doi.org/10.1007/s10461-018-2184-4. World Health Organization. HIV statistics, globally and by WHO region, 2024. Geneva, Switzerland: WHO; 2024. Supplementary Files Additioalfile3.pdf Additionalfile1.docx Additionalfile2.pdf Additionalfile4.docx Additionalfile5.docx Additionalfile6.pdf Additionalfile7.docx Addtionalfile8.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 05 Dec, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers invited by journal 17 Jun, 2025 Editor assigned by journal 11 Jun, 2025 First submitted to journal 21 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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by the epidemic of Human Immunodeficiency virus (HIV). Reported HIV prevalence in FSWs has exceeded that of other women of reproductive age by more than 13 times, with greater than half of FSWs found to be infected in some settings in sub-Saharan Africa (SSA) [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A number of behavioural, social and regulatory factors contribute to the higher risk of HIV in FSWs, particularly in the context of SSA. Substance abuse, violence, social marginalization and criminalization of sex work all weaken FSW\u0026rsquo;s ability to effectively use protective methods and increase their vulnerability to HIV-infection [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV-negative individuals for preventing acquisition of the infection, has emerged as a biomedical prevention method demonstrating high efficacy and safety across different population groups and exposure types [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. PrEP enhances self-protection among FSWs and provides an additional layer of protection along with other barrier methods such as condoms - which are effective only when both parties have the self-efficacy and commitment to consistently and appropriately use it, and may sometimes only be used subject to client approval [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany SSA countries officially endorsed offering PrEP to FSWs following the 2015 World Health Organization (WHO) recommendations for its use as part of combination HIV prevention for sexually active individuals at substantial risk of HIV infection - HIV incidence greater than 3 per 100 person\u0026ndash;years in the absence of PrEP [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, PrEP scale-up has been inadequate in the region [\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] adversely affecting the expected impact of the programme on the epidemic by reducing the burden of the disease on key populations such as FSWs, which could ultimately contribute to the prevention of community transmissions.\u003c/p\u003e \u003cp\u003eThe progression of a PrEP programme can effectively be evaluated by examining each step that the care process entails. Nunn and colleagues [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] proposed an expanded framework of PrEP care continuum to measure PrEP awareness, uptake, adherence, and retention in care. We adapted this framework to describe the situation of the PrEP care cascade (including awareness about PrEP, acceptability/willingness to use, uptake/actual use, adherence and retention in care) among FSWs in the SSA context.\u003c/p\u003e \u003cp\u003eDespite the fact that awareness is critical for engagement in the next stages of the care cascade, FSWs in SSA generally have low awareness about the existence and health importance of PrEP [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This might partly reflect the relative novelty of the method in the region and insufficient mobilization and education efforts in the target population. When adequately informed about its nature and role, however, FSWs often indicate high willingness to use [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the indications of acceptance, the actual use (uptake) is very low due to a range of personal, social and structural barriers including: low risk perception, social stigma related to both sex work and HIV, lack of social support and limited access [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Poor adherence and inappropriate discontinuations (discontinuation of PrEP care being considered appropriate when there is low/no risk of infection) are high among those who initiated [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], substantially hindering efficacy of the method which is highly dependent on optimal adherence [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, a lack of standardised targets similar to those for HIV diagnosis and treatment, and limited implementation of user-centred delivery approaches further impeded PrEP scale-up in SSA [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence-based interventions are urgently required to improve the PrEP care continuum among FSWs in SSA. However, there has been only limited review of the existing literature synthesizing factors affecting the care continuum in the target population globally [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and even less in the context of SSA specifically [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] in order to suggest such interventions. As research related to the stages of the relatively recently established PrEP cascade may also be considered emerging, the available reviews lack currency and hence involve a limited number of primary studies. Moreover, none of the reviews comprehensively assessed the entire cascade of care, with some purely focused either on quantitative [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] or narrative aspects of findings [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Our review aimed to make both quantitative synthesis and qualitative exploration of available evidence on determinants of each component of the PrEP cascade among FSWs in SSA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe review has been reported based on the updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] (see Additional file 1) and registered in International Prospective Register of Systematic Reviews (PROSPERO; Number: CRD420250650765) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] (see Additional file 2).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eStudies\u003c/strong\u003e \u003cp\u003eObservational studies conducted in one or more countries in SSA were eligible for inclusion in the quantitative synthesis without restrictions based on type of design; whereas qualitative studies exploring barriers to and facilitators of PrEP care cascade components were included in the qualitative synthesis. While no restriction was made based on year of publication, quantitative studies focused on evaluating the effects of interventions and qualitative studies exploring FSWs\u0026rsquo; experience regarding these were excluded. Our review was also restricted to studies published in English language with full texts available and/or accessible.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePopulation\u003c/strong\u003e \u003cp\u003eWomen aged 18 years or above who engaged in sex work (i.e., selling sex in exchange for money or other valuable material) in the last month of the study commencement. Studies particularly focusing on sub-groups of the population of interest (e.g., FSWs who use drugs) were excluded due to possible unique vulnerability to risk behaviour that may not be generalizable to others.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExposure\u003c/strong\u003e \u003cp\u003eVarious levels of factors including structural, social and behavioural characteristics influencing any of the components of the care cascade.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eComparator\u003c/strong\u003e \u003cp\u003eWhile the absence of a certain exposure characteristic was considered as a comparator for synthesis of evidence, studies were not excluded from the review whether they made comparisons or not.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOutcomes\u003c/strong\u003e \u003cp\u003eAny of the components of the PrEP care cascade (i.e., awareness, acceptability, uptake, adherence or retention in care) without restricting inclusion based on measurement methods.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformation sources\u003c/strong\u003e \u003cp\u003eThe primary author (TGF) undertook searches on 12 June 2024 on four bibliographic databases including Medline through Ovid and PubMed for non-Medline articles, and CINAHL and Web of Science through EBSCOhost and Clarivate respectively. He searched the grey literature through Google Scholar on 23 December 2024 and, selected and screened the first 100 results on title. TGF also manually examined reference lists of systematic reviews conducted on a similar topic as well as of studies included in the current review to identify additional studies. We set up email alerts to track on an on-going basis relevant articles indexed by the databases.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSearch strategy\u003c/strong\u003e \u003cp\u003eTGF, who has a prior database search experience developed a search strategy based on concepts of \u0026ldquo;factors\u0026rdquo; AND \u0026ldquo;pre-exposure prophylaxis\u0026rdquo; AND \u0026ldquo;female sex workers\u0026rdquo;. Search terms related to these concepts were identified by reviewing the titles and abstracts of five known relevant studies and a draft search strategy was constructed using the initial terms. The strategy identified all five studies when tested on Medline. To align with the eligibility criteria, the search strategy was limited to English-language studies and to those conducted on women. We used the search string \u0026ldquo;pre-exposure prophylaxis\u0026rdquo; AND \u0026ldquo;female sex workers\u0026rdquo; to conduct a search on Google Scholar. The full search strategy for all databases is provided in the additional file (see Additional file 3).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSelection process\u003c/strong\u003e \u003cp\u003eResults of the search were first checked for duplicates using EndNote\u0026rsquo;s duplicate identification function and then searched manually to identify and delete those not detected by the function. TGF conducted initial screening of titles and abstracts of the remaining articles to identify potentially eligible studies and to further assess available full text against the eligibility criteria. Excluded articles were verified by one of the co-authors (TLE) and disagreements between the reviewers were resolved by consensus.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eData collection process\u003c/b\u003e: Data were extracted using a checklist adapted from the Cochrane Checklist for Data Collection [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] (see Additional file 4). The checklist captured information related to characteristics of the studies including: authors, year of publication, country, participants, methods and designs used, outcomes assessed and measurement instruments, and the main findings of the study. The primary author (TGF) undertook data collection from the included studies which was then checked by TLE for any errors, with disagreements being resolved through discussion.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData items\u003c/strong\u003e \u003cp\u003eThe eligible outcomes were awareness of PrEP (often referred to as \u0026ldquo;ever heard of\u0026rdquo;), acceptability (\u0026ldquo;willingness to use\u0026rdquo;), uptake (\u0026ldquo;ever use\u0026rdquo;), adherence (\u0026ldquo;compliance to dose\u0026rdquo;) and retention in care (\u0026ldquo;attending a follow-up visit\u0026rdquo;) at a given timeframe. All results that were compatible with each outcome definition from each study were sought with no restrictions on time points or measurements.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy risk of bias assessment\u003c/b\u003e: We used the Cochrane \u0026ldquo;Risk of bias\u0026rdquo; tool for non-randomised studies \u0026ndash; of exposure (ROBINS-E) to assess risk of bias in the included studies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] (see Additional file 5). The tool begins with three items \u0026ndash; authors\u0026rsquo; attempt to control confounders, appropriateness of methods used to measure exposure and outcomes. This informs the decision whether to proceed with further assessment with failure to meet any of the requirements indicating a \u0026ldquo;very high risk of bias\u0026rdquo; and requires no further assessment. The main part of the tool contains seven domains of bias: i) bias due to confounding; ii) bias arising from measurement of the exposure; iii) bias in selection of participants; iv) bias due to post-exposure intervention; v) bias due to missing data; vi) bias arising from measurement of the outcome; and vii) bias in selection of reported results. Each domain was addressed by answering a series of signalling questions with response options: \u0026lsquo;Yes\u0026rsquo;, \u0026lsquo;Probably Yes\u0026rsquo;, \u0026lsquo;Probably No\u0026rsquo;, \u0026lsquo;No\u0026rsquo; and \u0026lsquo;No information\u0026rsquo;. Judgements on the risk of bias arising from each domain made (as \u0026ldquo;Low risk of bias\u0026rdquo;, \u0026ldquo;Some concerns\u0026rdquo;, \u0026ldquo;High risk of bias\u0026rdquo; and \u0026ldquo;Very high risk of bias\u0026rdquo;) using an inbuilt algorithm based on responses to the signalling questions. Finally, an overall judgement was made based on domain-level judgements using an algorithm given for this purpose.\u003c/p\u003e \u003cp\u003eThe methodological quality of included qualitative studies was assessed using the JBI Critical Appraisal Checklist for Qualitative Research [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] (see Additional file 6). The checklist mainly addresses quality issues related to congruity between the philosophical perspective, methodology, research question, data collection methods, and analysis and interpretation. It also raises questions concerning the researcher\u0026rsquo;s cultural and theoretical influence on the research, representation of participants and their voices and whether the study has an ethical approval from an appropriate body. Both quantitative and qualitative studies were initially assessed for risk of bias by the primary author (TFG) and then the results were checked by the co-author (TLE) with discrepancies resolved by discussion.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData synthesis\u003c/strong\u003e \u003cp\u003eVariation (methodological heterogeneity) among studies in assessing types of exposures, especially among those investigating \u0026ldquo;uptake\u0026rdquo; and/or \u0026ldquo;acceptability\u0026rdquo; (although the outcomes were generally assessed in a similar way), and in measuring adherence and retention in care, precluded conducting any statistical synthesis of quantitative results. Therefore, we provided a narrative synthesis of both quantitative and qualitative results and integrated the findings in the discussion section for interpretation.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003eOur search identified 856 records from the bibliographical databases (including two records obtained from email alerts). After duplicate removal, 588 records were screened, of which 501 were excluded based on title and/or abstract review. A further 48 records were identified in Google Scholar (25), and by reviewing the reference lists of previous relevant systematic reviews and of the included studies (23). Of 128 reports sought for retrieval from all sources, 68 were retrieved for eligibility assessment and 53 reports were finally included in the review as depicted in the PRISMA flow diagram below (see Fig.\u0026nbsp;1). Three studies [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] were found to be potentially relevant for which full text was not accessible.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1: PRISMA flow diagram showing study selection process\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy characteristics\u003c/h3\u003e\n\u003cp\u003eThe majority (43 of 53) of studies were obtained from eastern and southern parts of SSA. Accordingly, eight studies were conducted in Uganda [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41 CR42 CR43 CR44 CR45\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], seven in South Africa [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR48 CR49 CR50\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], six in Ethiopia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53 CR54 CR55\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], another six in Rwanda [\u003cspan additionalcitationids=\"CR58 CR59 CR60 CR61\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] and five in Tanzania [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR64 CR65\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. While Kenya [\u003cspan additionalcitationids=\"CR68 CR69\" citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] and Zimbabwe [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR72\" citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e] each contributed four studies, Zambia [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e], Nigeria [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e], Malawi [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e] and Benin [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e] had two studies each. The remaining five studies were conducted in Botswana [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e], Ghana [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e], Senegal [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e], Cameroon [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e] and the Democratic Republic of Congo [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main characteristics of quantitative studies included in the review are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of 35 studies, most (25) employed a cross-sectional design [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53 CR54 CR55\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan additionalcitationids=\"CR77\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e] and ten used a follow-up design - five prospective [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e] and the other five retrospective designs [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Three studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] used a mixed-methods approach with all using a cross-sectional design for their quantitative component.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of quantitative studies assessing PrEP care continuum among female sex workers in sub-Saharan Africa\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExposure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrEP outcome assessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOutcome measurement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eResults and conclusions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e**Beckham \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e293 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-Perceived HIV risk\u003c/p\u003e \u003cp\u003e-Social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of PrEP (yes/no)\u003c/p\u003e \u003cp\u003eb) Thinking PrEP is worth taking (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 8%; acceptability 58%\u003c/p\u003e \u003cp\u003e*Acceptability independently associated with having STI symptoms in the past six months (AOR 2.52; 95%CI: 1.38\u0026ndash;4.62) and higher social cohesion (AOR 2.12; 95%CI: 1.29\u0026ndash;3.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChimbindi \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e194 young (18-24yrs old) FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of PrEP (yes/no)\u003c/p\u003e \u003cp\u003eb) Ever use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 11%; uptake 0%\u003c/p\u003e \u003cp\u003e*No analyses performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChuru \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e360 FSWs on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-Perception of PrEP\u003c/p\u003e \u003cp\u003e-Attitude towards PrEP service delivery\u003c/p\u003e \u003cp\u003e-Social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-Pill count indicating\u0026thinsp;\u0026gt;\u0026thinsp;95% use in the last month\u003c/p\u003e \u003cp\u003e-Self-report on\u003c/p\u003e \u003cp\u003edaily use in the last month indicating\u0026thinsp;\u0026gt;\u0026thinsp;95% use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdherence 48.3% based on pill count and 43.3% based on self-report\u003c/p\u003e \u003cp\u003e* Pill count adherence significantly associated with living with family members compared to friends (AOR 2.32; 95%CI: 1.27\u0026ndash;4.23); favorable approval towards current pill packaging (AOR 2.43; 95%CI: 1.41\u0026ndash;4.19); and having a positive perception of PrEP (AOR 1.71; 95%CI: 1.01\u0026ndash;2.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFaini \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-700 FSWs for awareness\u003c/p\u003e \u003cp\u003e-231FSWs for acceptability\u003c/p\u003e \u003cp\u003e-469 FSWs for current use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePerceived HIV risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003cp\u003ec) Current use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of PrEP (yes/no)\u003c/p\u003e \u003cp\u003eb) Willingness to use (yes/no)\u003c/p\u003e \u003cp\u003ec) Being on PrEP (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 67%; acceptability 98%; current use 8%\u003c/p\u003e \u003cp\u003e*Current use significantly associated with having a long-term partner (AOR 4.19; 95% CI: 1.44\u0026ndash;12.18); and having sex with an HIV-infected partner in the last three months (AOR 3.98; 95% CI: 1.20- 13.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuure \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5107 FSWs for acceptability\u003c/p\u003e \u003cp\u003e-998 FSWs for uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-PrEP awareness\u003c/p\u003e \u003cp\u003e-Perceived HIV risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Acceptability\u003c/p\u003e \u003cp\u003eb) Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Willingness to use (yes/no)\u003c/p\u003e \u003cp\u003eb) Ever use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcceptability 53.6%; uptake 6.4%\u003c/p\u003e \u003cp\u003e*Acceptability positively associated with PrEP awareness (AOR 2.59; 95%CI: 2.22\u0026ndash;2.98); entry into sex work at age\u0026thinsp;\u0026lt;\u0026thinsp;25yrs compared to those 25 to 34yrs (AOR 0.84; 95%CI: 0.72\u0026ndash;0.95); having been in a long-term relationship (AOR 1.52; 95%CI: 1.09\u0026ndash;2.01); having been screened for STI (AOR 1.23; 95%CI: 1.10\u0026ndash;1.40); and injecting drug use (AOR 5.31; 95%CI: 1.64\u0026ndash;10.60)\u003c/p\u003e \u003cp\u003e*Uptake significantly associated with having been screened for STI (AOR 5.2; 95%CI: 1.68\u0026ndash;11.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e**Hensen \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e538 young (18-24yrs old) FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-Perceived HIV risk\u003c/p\u003e \u003cp\u003e-Social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea)\u0026nbsp;Awareness b) Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of PrEP (yes/no)\u003c/p\u003e \u003cp\u003eb) Ever use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 96%; uptake 34%\u003c/p\u003e \u003cp\u003e*Uptake significantly associated with reporting more (10+) clients in the past month (AOR 1.71; 95%CI: 1.06\u0026ndash;2.76); duration (2\u0026ndash;3 years) of selling sex compared to lesser duration (AOR 0.51; 95%CI: 0.32\u0026ndash;0.83); positive perception of peer support to PrEP use compared to negative perception (AOR 0.54; 95% CI: 0.31\u0026ndash;0.95) and visiting female sex worker program (AOR 2.92; 95%CI: 1.91\u0026ndash;4.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeis \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-215 FSWs for magnitude of uptake and current use\u003c/p\u003e \u003cp\u003e-160 FSWs for final analysis of current use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClient-perpetrated violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Current use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea)\u0026nbsp;Ever use (yes/no)\u003c/p\u003e \u003cp\u003eb) Being on PrEP (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 61%; current use 46.5%\u003c/p\u003e \u003cp\u003e*While recent client-perpetrated emotional violence associated with decreased current use (AOR 0.23; 95%CI: 0.07\u0026ndash;0.71), client-perpetrated physical violence associated with increased current use (AOR 3.01; 95%CI: 1.16\u0026ndash;7.81))\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLichtwarck \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e470 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProspecti-ve Follow- up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-Mental distress\u003c/p\u003e \u003cp\u003e-Perceived HIV risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRetention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePresenting for 56 days follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRetention in care 25.4%\u003c/p\u003e \u003cp\u003e*While mental distress was associated with increased risk of disengagement (ARR 1.14; 95%CI: 1.01\u0026ndash;1.27), having higher number of clients (\u0026ge;\u0026thinsp;30) per month associated with lower risk (ARR 0.80; 95% CI: 0.68\u0026ndash;0.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e**Litiema \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e345 FSWs on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBehavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-Self-report on\u003c/p\u003e \u003cp\u003edaily use in the last month\u003c/p\u003e \u003cp\u003e-Pharmacy refill\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSelf-reported adherence 61%; refill adherence 67%\u003c/p\u003e \u003cp\u003e*Considering to stop PrEP (AOR 3.86; 95%CI: 2.11\u0026ndash;7.06 ) and use of reminder (AOR 1.85; 95%CI: 1.12\u0026ndash;3.02) positively associated with self-reported adherence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShibesh \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e334 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-Perceived HIV risk\u003c/p\u003e \u003cp\u003e-Social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of PrEP (yes/no)\u003c/p\u003e \u003cp\u003eb) Ever use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 27.3%; uptake 15.9%\u003c/p\u003e \u003cp\u003e*While death of either parent (only father alive: AOR 0.23, 95%CI: 0.02\u0026ndash;0.64; only mother alive: AOR 0.31; 95% CI: 0.02\u0026ndash;0.74) and being single (AOR 0.27; 95% CI: 0.06\u0026ndash;0.94) negatively associated with PrEP uptake, having a history of STI positively associated (AOR 2.82; 95%CI: 1.60\u0026ndash;4.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSarr \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSenegal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e267 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProspective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Adherence\u003c/p\u003e \u003cp\u003ec)Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Initiated on PrEP\u003c/p\u003e \u003cp\u003eb) -Electronic monitoring (EM) of each opening of the pill container\u003c/p\u003e \u003cp\u003e-Blood TFV level of \u0026gt;\u0026thinsp;35.5 ng/ml, consistent with daily dosing of Truvada in a week\u003c/p\u003e \u003cp\u003ec) Making consecutive quarterly clinic visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-Uptake 82.4%\u003c/p\u003e \u003cp\u003e-EM adherence 80% at 1st month, 50% 2nd month; blood drug level adherence 42.6% at 3rd month, 21.7% at 6th month\u003c/p\u003e \u003cp\u003e-Retention in care 79.9% at 6th month, 73.4% at 12th month\u003c/p\u003e\u003cp\u003e*No sociodemogrphic factors associated with retention in care\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRao \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2776 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Initiation on PrEP\u003c/p\u003e \u003cp\u003eb) Attending a\u003c/p\u003e \u003cp\u003emonthly appointment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 27.5%; retention in care at 1st month 53%, 33% at 4th month, 18% at 7th month and 9% at 12th month\u003c/p\u003e \u003cp\u003e*Younger women (\u0026lt;\u0026thinsp;25yrs old) less likely to be retained in care (SHR 0.82; 95%CI: 0.76\u0026ndash;0.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRao \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12,581 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Retention in care\u003c/p\u003e \u003cp\u003ec) Re-initiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Initiation on PrEP\u003c/p\u003e \u003cp\u003eb) Making monthly visits\u003c/p\u003e \u003cp\u003ec) Restarting\u003c/p\u003e \u003cp\u003eafter a\u0026thinsp;\u0026ge;\u0026thinsp;2 months gap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 19%; retention in care at 1st month 41%; re-initiation 9%\u003c/p\u003e \u003cp\u003e*No analyses made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNdenkeh \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCameroon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13,738 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProspective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Initiating on PrEP\u003c/p\u003e \u003cp\u003eb) Drug refill at 12th month of initiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 61%; retention in care at 12th month 5%\u003c/p\u003e \u003cp\u003e*No analyses performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNalukwago \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBehavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-report on taking at least six out of seven doses in a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdherence 71. 4%;\u003c/p\u003e \u003cp\u003e*Using long-term contraceptives (AOR 0.06; 95%CI: 0.04\u0026ndash;0.77) and not using condoms with clients (AOR 0.07; 95%CI: 0.01\u0026ndash;0.42) negatively associated with adherence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNakiganda \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e524 FSWs on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePerceived HIV risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-A pill count of \u0026ge;\u0026thinsp;85% in the last 3 months\u003c/p\u003e \u003cp\u003e-Self-report on\u003c/p\u003e \u003cp\u003etaking every day in the last 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePill count adherence 71%; self-report adherence 50.4%\u003c/p\u003e \u003cp\u003e*Pill count adherence positively associated with age\u0026thinsp;\u0026ge;\u0026thinsp;35yrs (AOR 2.40; 95%CI: 1.17\u0026ndash;4.86), having an STI in last 3 months (AOR 1.64; 95%CI: 1.07\u0026ndash;2.49) and having\u0026thinsp;\u0026ge;\u0026thinsp;100 sexual partners within 3 months (AOR 2.56; 95%CI: 1.37\u0026ndash;4.73), but negatively associated with an intention to use only when felt at risk (AOR 0.26; 95%CI: 0.15\u0026ndash;0.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMboup \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBenin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e255 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProspective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBehavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTFV blood concentration\u0026thinsp;\u0026ge;\u0026thinsp;35.5 ng/mL, consistent with taking all 7 pills in a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOverall adherence (i.e., 14days, 6, 12, 18 and 24 months adherence combined) 34.1%\u003c/p\u003e \u003cp\u003e*Age (25-34yrs: AOR 2.41; 95%CI: 1.01\u0026ndash;5.74; 35-44yrs: AOR 4.38; 95%CI: 1.79\u0026ndash;10.75; \u0026ge;45yrs: AOR 3.70; 95%CI:1.32\u0026ndash;10.35 compared to \u0026lt;\u0026thinsp;25yrs), duration of follow-up (at 6th month: AOR 0.33; 95%CI: 0.21\u0026ndash;0.52; 12th month: AOR 0.24; 95%CI: 0.14\u0026ndash;0.42; 18th month: AOR 0.22; 95%CI: 0.12\u0026ndash;0.42; 24th month: AOR 0.11; 95%CI: 0.04\u0026ndash;0.28 compared to day 14) and intention to adhere (AOR 2.65, 95%CI:1.46\u0026ndash;4.81) associated with adherence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMartin \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e428 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic factors\u003c/p\u003e \u003cp\u003e-Perceived HIV risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Current use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever use (yes/no)\u003c/p\u003e \u003cp\u003eb) Being on PrEP (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 54.7%; current use 53%\u003c/p\u003e \u003cp\u003e*Uptake associated with having three or more children (AOR 2.14; 95%CI: 1.08\u0026ndash;4.25) and positive attitude towards PrEP (AOR 2.83; 95%CI: 1.75\u0026ndash;4.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFranks \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDRC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e352 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Initiation on PrEP\u003c/p\u003e \u003cp\u003eb) Attending clinic appointments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 78.7%; retention in care 62.1% at 1st month\u003c/p\u003e \u003cp\u003e*No analyses performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLancaster \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of PrEP (yes/no)\u003c/p\u003e \u003cp\u003eb) Willingness to use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 21%; acceptability 96%\u003c/p\u003e \u003cp\u003e*No analyses performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMboup \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBenin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e256 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProspective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-report on daily use\u003c/p\u003e \u003cp\u003ein the last month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdherence 78% at day 14; 43.3% at 24th month\u003c/p\u003e \u003cp\u003e*No analyses performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMudzviti and Dhliwayo [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-PrEP knowledge\u003c/p\u003e \u003cp\u003e-Perceived HIV risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Knowledge\u003c/p\u003e \u003cp\u003ec) Acceptability\u003c/p\u003e \u003cp\u003ed) Likelihood of use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of PrEP (yes/no)\u003c/p\u003e \u003cp\u003eb) Estimated using relative importance index (RII\u0026thinsp;\u0026gt;\u0026thinsp;0.5)\u003c/p\u003e \u003cp\u003ec) Willingness to use (yes/no)\u003c/p\u003e \u003cp\u003ed) Estimated using relative importance index (RII: range 0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 54%; knowledge 35% of those aware; acceptability 78% of the total; median RII score of the likelihood of use 0.89\u003c/p\u003e \u003cp\u003e*Increase in age (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0033, p 0.038), having unprotected sex in the last 3-months (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0448, p 0.026), having good knowledge about PrEP (r\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;=\u0026thinsp;0.0153) and decrease in barriers (r\u0026thinsp;=\u0026thinsp;0.23, p\u0026thinsp;=\u0026thinsp;0.0074) associated with the increase in the likelihood of use\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWitte \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-273 FSWs for Acceptability\u003c/p\u003e \u003cp\u003e-283 for Initiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-Social support\u003c/p\u003e \u003cp\u003e-Social stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Acceptability\u003c/p\u003e \u003cp\u003eb) Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Willingness to use (yes/no)\u003c/p\u003e \u003cp\u003eb) Initiation on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAcceptability 91%; uptake 55%\u003c/p\u003e \u003cp\u003e*-Acceptability negatively associated with more (\u0026ge;\u0026thinsp;5) years in sex work (AOR 0.18; 95% CI: 0.05\u0026ndash;0.066) and positively associated with greater perceived social support from family (AOR 1.39; 95% CI: 1.03\u0026ndash;1.88)\u003c/p\u003e \u003cp\u003e-Uptake negatively associated with greater perceived social support from friends (AOR 0.81; 95%CI: 0.68\u0026thinsp;\u0026minus;\u0026thinsp;0.97) and positively associated with a higher perceived stigma due to sex work among family members (AOR 2.20; 95%CI:1.15\u0026thinsp;\u0026minus;\u0026thinsp;4.22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdeme \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e396FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic and behavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Knowledge\u003c/p\u003e \u003cp\u003eb) Current use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) A score of \u0026ge;\u0026thinsp;50% on 11-item PrEP knowledge scale\u003c/p\u003e \u003cp\u003eb) Being on PrEP (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eKnowledge 51%; current use 46.2%\u003c/p\u003e \u003cp\u003e*While being older aged (26\u0026ndash;36 years compared to 18\u0026ndash;21 years: AOR 0.20; 95%CI: 0.17\u0026ndash;0.84) and longer duration of engagement in sex work (3\u0026ndash;5 years compared to \u0026lt;\u0026thinsp;3 years: AOR 0.25; 95%CI: 0.24\u0026ndash;0.82) negatively associated with current use, attending secondary and above education (AOR 2.18; 95%CI: 1.05\u0026ndash;4.53) and having a good knowledge about PrEP (AOR 4.98;95%CI: 3.90\u0026ndash;10.65) positively associated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerhe \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e358FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic, behavioural and structural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of (yes/no)\u003c/p\u003e \u003cp\u003eb) Willingness to use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 82%; acceptability 67.9%\u003c/p\u003e \u003cp\u003e*Knowledge about PrEP (AOR 3.27; 95%CI: 1.30\u0026ndash;8.23) and perceived ease of access (AOR 3.79; 95%CI: 1.50\u0026ndash;9.56) associated with acceptability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBongomin \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e273FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic and behavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-report on daily use in the past 3-months (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAdherence 66.3%\u003c/p\u003e \u003cp\u003e*Having source of income other than sex-work (AOR 3.7; 95%CI:2.11\u0026ndash;6.35), undertaking sex-work both in urban and rural setting (AOR 2.5; 95%CI: 1.49\u0026ndash;4.35), experience of depression (AOR 3.3; 95%CI: 1.43\u0026ndash;7.74) and of post-exposure prophylaxis use (AOR 2.46; 95%CI:1.61\u0026ndash;3.77) positively associated with adherence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHussein \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e422FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic and behavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of (yes/no)\u003c/p\u003e \u003cp\u003eb) Willingness to use score of greater than a mean value on a 5-point response scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 22.5%; acceptability 68%\u003c/p\u003e \u003cp\u003e*While younger age (18\u0026ndash;23 years: AOR 2.9; 95%CI: 1.2\u0026ndash;7.4) and being aware of PrEP (AOR 3.9; 95%CI: 1.9\u0026ndash;7.96) associated with a higher likelihood of acceptability, lower educational status (AOR 0.36; 95%CI: 0.2\u0026ndash;\u003c/p\u003e \u003cp\u003e0.6) associated with lower likelihood of acceptability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMubezi \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRwanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e268FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic and behavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRetention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAttending monthly and then three-monthly scheduled visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRetention in care 81% at 1st month, 67% and 53% at 6th and 12th month respectively\u003c/p\u003e \u003cp\u003e*While a desire to have more (\u0026ge;\u0026thinsp;2) children (AHR 1.65; 95%CI: 1.01\u0026ndash;2.71) and use of hormonal methods of contraception (AHR 2.09; 95%CI:1.18\u0026ndash;3.70) or non-use (AHR 2.04; 95%CI: 1.01\u0026ndash;4.12) compared to condom increased the chance of retention in care, seldom (AHR 0.41; 95%CI: 0.228\u0026ndash;0.749) or non-use of condom during sex (AHR 0.33; 95%CI: 0.15\u0026ndash;0.73) and urban residence (AHR 0.29; 95%CI: 0.18\u0026ndash;0.46) decreased the chance of retention in care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaluwogo and Kansiime [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEver use of PrEP (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 61.3%\u003c/p\u003e \u003cp\u003e*No analysis performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNwagbo \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e260FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003cp\u003ec) Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of (yes/no)\u003c/p\u003e \u003cp\u003eb) Willingness to use score of greater than a mean value on a 5-point response scale\u003c/p\u003e \u003cp\u003ec) Ever use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 31.2%; acceptability 91%; uptake 3.9%\u003c/p\u003e \u003cp\u003e*No analysis performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNzungize and Munyaneza [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRwanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e333FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBehavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of (yes/no)\u003c/p\u003e \u003cp\u003eb) Willingness to use (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 81%; acceptability 80%\u003c/p\u003e \u003cp\u003e*History of STI screening in the last 12-months compared to having no history (AOR 0.28; 95%CI:0.12\u0026ndash;0.62) and perception of PrEP benefits compared to no perception (AOR 0.06; 95%CI: 0.16\u0026ndash;0.29) associated with acceptability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOmo-Emmanuel \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e344FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic and behavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003cp\u003ec) Uptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Correctly answering 2 out of 3 PrEP knowledge questions\u003c/p\u003e \u003cp\u003eb) A score of \u0026gt;\u0026thinsp;75% on willing to use questions\u003c/p\u003e \u003cp\u003ec) Ever use (ye/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 76.5%; acceptability 8.1%; uptake 42.4%\u003c/p\u003e \u003cp\u003e*-Awareness associated with younger age (\u0026lt;\u0026thinsp;34 years: AOR 3.02; 95%CI: 1.05\u0026ndash;8.69), being single (AOR 3.10; 95%CI: 1.27\u0026ndash;7.58) and shorter duration of sex work (\u0026le;\u0026thinsp;5 years: AOR 2.62; 95%CI: 1.39\u0026ndash;4.92)\u003c/p\u003e \u003cp\u003e-Acceptability associated with more (\u0026gt;\u0026thinsp;11) weekly number) of clients compared to less (AOR 0.13; 95%CI: 0.03\u0026ndash;0.56), more number of weekly new clients (AOR 3.53; 95%CI: 1.05\u0026ndash;11.82) and condom non-use during sex compared to use (AOR 0.75; 95%CI: 0.60\u0026ndash;5.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUmulisa \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRwanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e273FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCurrent use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBeing on PrEP (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCurrent use 60.4%\u003c/p\u003e \u003cp\u003e*No analysis performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWanyama \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e350FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBehavioural and structural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRetention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAttending first month clinic visit since PrEP initiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRetention in care 32.3%\u003c/p\u003e \u003cp\u003e*Perceived good treatment by PrEP provider increased the likelihood of retention in care (AIRR 1.23; 95%CI: 1.05\u0026ndash;1.44] while enacted social stigma decreased the likelihood (AIRR 0.9; 95%CI: 0.814\u0026ndash;0.996)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRugira E \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRwanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4824FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEver engaged in PrEP (record review)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 45.6%\u003c/p\u003e \u003cp\u003e*No analysis performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiro \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBotswana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1254 for uptake\u003c/p\u003e \u003cp\u003e-207FSWs for adherence and retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Adherence\u003c/p\u003e \u003cp\u003ec) Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever engaged in PrEP (record review)\u003c/p\u003e \u003cp\u003eb) Drug refill (record review)\u003c/p\u003e \u003cp\u003ec) Retention in care for \u0026ge;\u0026thinsp;6 months or until the risk period is over (record review)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 16.5%; adherence 72.9%; retention in care 16.9%\u003c/p\u003e \u003cp\u003e*While employed FSWs more likely to adhere (AOR 2.36; 95%CI: 1.04\u0026ndash;5.57, younger FSWs (18\u0026ndash;29 years old: AOR 0.12; 95%CI: 0.03\u0026ndash;0.41) less likely to be retained\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMunyaneza \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRwanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1343FSWs\u003c/p\u003e \u003cp\u003e-996 FSWs for final analysis of retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic and behavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Acceptability\u003c/p\u003e \u003cp\u003ec) Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever heard of (yes/no-record review)\u003c/p\u003e \u003cp\u003eb) Willingness to use (yes/no-record review)\u003c/p\u003e \u003cp\u003ec) Attending scheduled appointments (record review)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAwareness 62%; acceptability 93%; retention in care at 1st month 92%, 90% at 3rd month, 86% at 6th month 78% at 9th month and 76% at 12th month\u003c/p\u003e \u003cp\u003e*While living with someone decreased the likelihood of first month retention in care (AOR 0.59; 95%CI: 0.35\u0026ndash;0.99), being employed (AOR 2.36; 95%CI: 1.28\u0026ndash;4.32) and perception of HIV risk due to sex work increased the likelihood (both 1st and 12th month retention) compared to a lack of risk perception (1st month: AOR 0.11; 95%CI: 0.04\u0026ndash;0.29; 12th month: AOR 0.35; 95%CI: 0.12\u0026ndash;0.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsmare \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e549FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSociodemo-graphic and behavioural factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Current use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ea) Ever use (yes/no)\u003c/p\u003e \u003cp\u003eb) Being on PrEP (yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUptake 33.3%; current use 28.8%\u003c/p\u003e \u003cp\u003e*While attending higher education (college and above: measure of association (β) 0.89; 95%CI: 0.52\u0026ndash;1.08) and knowledge about PrEP (β 1.94; 95%CI: 0.99\u0026ndash;2.89) had a positive total (direct and indirect) effect on current use being mediated by PrEP knowledge and attitude respectively, engagement in sex work for longer period (3\u0026ndash;5 years: β 0.53; 95%CI: 0.06\u0026ndash;1.01) had a direct positive effect\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eAHR: Adjusted hazard ratio; AIRR: Adjusted incidence rate ratio; AOR: Adjusted odds ratio; CI: Confidence interval; DRC: Democratic Republic of Congo; FSWs: Female sex workers; PrEP: Pre-exposure prophylaxis; SHR: sub-Hazard ratio; STI: Sexually transmitted infections: TFV: Tenofovir\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*R\u003csup\u003e2\u003c/sup\u003e is the extent to which dependent variable can be predicted by predictor variables\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*r is a correlation between independent and dependent variables\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e** Represents a quantitative arm of a mixed-methods study\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe main characteristics of qualitative studies included in the review are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Nine of the fifteen studies applied in-depth interviewing (IDI) for data collection [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e], three undertook focus-group discussion (FGD) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e] and a further three used both techniques [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. The three mixed-methods studies applied IDI [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and both IDI and FGD [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] for their qualitative components.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of qualitative studies exploring PrEP care continuum among female sex workers in sub-Saharan Africa\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eData collection technique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePrEP outcome assessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDefinition of the outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFindings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmogne \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17FSWs on PrEP and not initiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Initiation on PrEP\u003c/p\u003e \u003cp\u003eb) Daily use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Doubts or misconceptions about the effectiveness of PrEP over condoms; uncertainty about how to use condoms and PrEP together\u003c/p\u003e \u003cp\u003e-Lack of understanding about the difference between PrEP and ART\u003c/p\u003e \u003cp\u003e-Perceived bill burden and side effects\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of uptake\u003c/b\u003e: Feeling responsibility for taking care of self and others (e.g., children)\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers to adherence\u003c/b\u003e: Side-effects and pill size; stigma related to HIV; forgetting in relation to the nature of sex work (e.g., day time sleep)\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBazzi \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWillingness to use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Lack of knowledge/information about PrEP\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Perception of being at risk of HIV infection (because of perceived low self-efficacy to consistently use condom which was attributed to partner refusal, condom burst, substance/alcohol abuse, forgetting, high pay, poverty and violence)\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e**Beckham \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10FSWs-IDIs\u003c/p\u003e \u003cp\u003e20FSWs-FGDs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI and FGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThinking PrEP is worth taking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers\u003c/b\u003e: Perceived HIV related stigma from clients; perceived pill burden while being healthy\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators\u003c/b\u003e: Perception of being at risk of HIV infection (e.g., alcohol or other substance abuse)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusza \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Adherence\u003c/p\u003e \u003cp\u003ec) Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Ever use\u003c/p\u003e \u003cp\u003eb) Daily use\u003c/p\u003e \u003cp\u003ec) Attending health facility visits to collect drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eFacilitators of uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Information from health care provider and peers\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of adherence\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e- The use of individual strategies as medication reminders (e.g., linking to daily events such as tooth brushing); and peer support\u003c/p\u003e \u003cp\u003e\u003cb\u003eBarriers to retention in care\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Early experience of side-effects\u003c/p\u003e\u003cp\u003e-Frequent health facility visits during the earlier phases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEakle \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Ever use\u003c/p\u003e \u003cp\u003eb) Daily use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Lack of awareness of PrEP due to its novelty\u003c/p\u003e \u003cp\u003e-Disbelief in PrEP efficacy\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of uptake\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Being responsible for family and oneself (i.e., desire to remain healthy, safe, happy and hopeful)\u003c/p\u003e\u003cp\u003e-Perceived risk of becoming infected (related to violence, intentional (by clients)/unintentional condom breakage and long-term romantic/sexual relationship)\u003c/p\u003e\u003cp\u003e\u003cb\u003eFacilitators of adherence\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Subsequent negative HIV test results\u003c/p\u003e\u003cp\u003e-Use of personal strategies as reminder for pill taking (e.g., setting alarms, linking with daily routines, etc.)\u003c/p\u003e\u003cp\u003e-Peer/family support; friendly health staff\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEakle \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Ever use\u003c/p\u003e \u003cp\u003eb) Daily use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Low awareness of PrEP\u003c/p\u003e \u003cp\u003e-Perceived side-effects; not being sick\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Perception of being at risk of HIV infection (related to condom burst, client refusal, violence, condomless sex with a main partner in the face of risky behaviour)\u003c/p\u003e \u003cp\u003e- Supportive/non-judgmental, flexible and tailored services; social support\u003c/p\u003e \u003cp\u003e\u003cb\u003eBarriers to adherence\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- Forgetting due to substance/alcohol abuse\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of adherence\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Aligning pill taking with daily routines\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e**Hensen \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 young (18-24yrs old) FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea)Uptake\u003c/p\u003e \u003cp\u003eb) Retention in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Ever use\u003c/p\u003e \u003cp\u003eb) Attending health facility visits to collect drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake\u003c/b\u003e: fear of disclosing sex work; HIV/ART-related stigma; lack of support and opportunity cost of accessing\u003c/p\u003e \u003cp\u003e\u003cb\u003eBarriers to retention in care\u003c/b\u003e: side-effects; demanding nature of daily pill taking while being healthy; lack of family support due to misconception of PrEP with ART; perceived low HIV risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e**Litiema \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25FSWs on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI and FGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDose or refill adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers\u003c/b\u003e: stigma related to PrEP/HIV; substance/alcohol abuse; daily pill taking; nature of work (e.g., mobility); limited counselling on side-effects; limited peer/partner support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStoebenau \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZambia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-25FSWs\u003c/p\u003e \u003cp\u003e-10Stakeholders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDIs and FGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Continuous use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Ever use\u003c/p\u003e \u003cp\u003eb) Persistence on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Anticipated drug side-effects as influenced by significant others\u003c/p\u003e \u003cp\u003e-The amplifying effects of confusing PrEP for ART (due to limited understanding among clients, social networks and society) which was rooted in HIV stigma\u003c/p\u003e \u003cp\u003e\u003cb\u003eBarriers to continuous use\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Experience of drug side-effects\u003c/p\u003e\u003cp\u003e-Excessive alcohol use; nature of sex work (e.g., mobility); forgetting; having to take a pill every day\u003c/p\u003e\u003cp\u003e- Health system related barriers such as long queues; clinic hours conflicting with work schedules\u003c/p\u003e\u003cp\u003e\u003cb\u003eFacilitators of uptake and continuous use\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Perceived HIV risk related to constrained self-capacity to use condoms due to alcohol use or pressure/more money/violence from clients\u003c/p\u003e\u003cp\u003e- Accountability and desire to protect family\u003c/p\u003e \u003cp\u003e- The presence of social support and welcoming/non-judgmental, convenient, and confidential (community-based) PrEP services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNhamo \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInitiation on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eMotivating factors for uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003ePerceived HIV risk related to condom burst or client refusal to use, partner/client violence or needing more money; being uncertain of clients HIV status\u003c/p\u003e \u003cp\u003e- Unexpected HIV negative results (due to risky sexual behaviour) during initiation\u003c/p\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003ePositive encouragement from others (such as peers, friends and family members)\u003c/p\u003e\u003cp\u003e-Family responsibility (e.g., taking care of children)\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMujugira \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEver use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eFacilitators of uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-A need for more money as a result of condomless sex\u003c/p\u003e \u003cp\u003e-Long-term relationship/partnership\u003c/p\u003e \u003cp\u003e\u003cb\u003eBarrier to uptake\u003c/b\u003e: Stigma related to PrEP being an ART drug\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakhakhe \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 total participants\u003c/p\u003e \u003cp\u003e-11 peer educators\u003c/p\u003e \u003cp\u003e-26 FSWs\u003c/p\u003e \u003cp\u003e-1 Counsellor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI and FGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUptake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEver use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eMotivators of uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Perception of sex work as a risk for HIV infection\u003c/p\u003e \u003cp\u003e-Having a long-term relationship\u003c/p\u003e \u003cp\u003e- Partners/clients refusal of using condoms\u003c/p\u003e \u003cp\u003e-Feeling of self and family responsibility\u003c/p\u003e \u003cp\u003e-Having future aspirations (e.g., having better job and healthy life)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmily \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZambia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-43 FSWs\u003c/p\u003e \u003cp\u003e-36 Sex work managers/Queen mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea) Uptake\u003c/p\u003e \u003cp\u003eb) Adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Ever use\u003c/p\u003e \u003cp\u003eb) Daily use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Perceived drug side-effects\u003c/p\u003e \u003cp\u003e-Perceived stigma related to ARV/HIV\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers to adherence\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Nature of work (e.g., mobility) and forgetting\u003c/p\u003e \u003cp\u003e-Experience of drug side-effects\u003c/p\u003e \u003cp\u003e-Stigma related to ARV/HIV\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakhakhe \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 total participants\u003c/p\u003e \u003cp\u003e-37 FSWs\u003c/p\u003e \u003cp\u003e-2 Health workers\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI and FGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUptake and continuous use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInitiating on PrEP and continue using\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake and continuous use\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e-Low risk perception by new entrants to sex work\u003c/p\u003e \u003cp\u003e- Perceived and enacted social stigma by peers, clients and partners related to HIV; as PrEP equated to/misperceived as ARV and this associated with risk of infection due to sex work\u003c/p\u003e \u003cp\u003e-Sex work stigma\u003c/p\u003e\u003cp\u003e-Limited understanding of PrEP services among health care workers\u003c/p\u003e\u003cp\u003e\u003cb\u003eFacilitator of uptake and continuous use\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e-Perceived HIV risk due to sex work\u003c/p\u003e\u003cp\u003e-Understanding PrEP as a self-controlled method\u003c/p\u003e \u003cp\u003e-Self-love and love of/feeling responsible for others (e.g., children), and possessing aspirations and goals for the future\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestar \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWillingness to use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to acceptability\u003c/b\u003e: Perceived burden of daily use and drug side-effects\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of acceptability\u003c/b\u003e: Perceived risk of infection due to a high possibility of unprotected sex; self-care/love\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShea \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWillingness to use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to acceptability\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- Perceived drug side-effects; burden of daily use; forgetting due to the nature of sex work (e.g., travel or staying out)\u003c/p\u003e \u003cp\u003e-Perceived diminished self-efficacy to consistently use due to excessive drinking\u003c/p\u003e\u003cp\u003e-Perceived stigma due to misconception of PrEP as ARVs\u003c/p\u003e\u003cp\u003e\u003cb\u003eFacilitators of acceptability\u003c/b\u003e: Perceived high risk of infection due to possible unprotected sex (condom break, client refusal to use condom, violence, long-term partnership, and a need for more money from condomless sex); self-love\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMpirirwe \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAccessing PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePicking up drugs from PrEP centres\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to access\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003eLimited counselling by providers attributable to limited training\u003c/p\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003eStigma related to HIV\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of accessing PrEP\u003c/b\u003e: Private delivery environment and friendly/non-judgmental providers\u003c/p\u003e\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoss \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRwanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14FSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ea) Awareness\u003c/p\u003e \u003cp\u003eb) Uptake\u003c/p\u003e \u003cp\u003ec) Continuous use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ea) Ever heard of (yes/no\u003c/p\u003e \u003cp\u003eb) Ever use (yes/no)\u003c/p\u003e \u003cp\u003ec) Being on PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eBarriers to uptake and continuous use\u003c/b\u003e: Stigma related to HIV (attributed to confusion between PrEP and ART) and to sex work itself\u003c/p\u003e \u003cp\u003e\u003cb\u003eFacilitators of uptake\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003eInformation from health care providers and social networks such as peers, friends, community mobilizers and FSWs associations\u003c/p\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003ePerceived risk of infection (related to possibilities of unprotected sex due to high number of clients, condom refusal, needing better incentive/money because of condomless sex)\u003c/p\u003e\u003cp\u003e-Feeling responsible for halting HIV transmission\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eART: Antiretroviral therapy; ARV: Antiretroviral; FGD: Focus group discuss; FSWs: Female sex workers; IDI: In-depth interview; PrEP; Pre-exposure prophylaxis;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e** Represents a qualitative arm of a mixed-methods study\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eTwenty-five quantitative [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53 CR54 CR55\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan additionalcitationids=\"CR77\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan additionalcitationids=\"CR83 CR84 CR85\" citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e] and nine qualitative studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] (including the respective arms of mixed-methods studies) assessed two or more components of the cascade. A total of fourteen quantitative studies [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53 CR54\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan additionalcitationids=\"CR77\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e] and one qualitative study [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] investigated awareness or knowledge about PrEP, and twelve quantitative [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan additionalcitationids=\"CR77\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e] and four qualitative studies assessed acceptability [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to six quantitative studies that investigated current (active) use of PrEP [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e], eighteen quantitative [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan additionalcitationids=\"CR83 CR84 CR85\" citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e] and twelve qualitative studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] assessed uptake. Nine quantitative studies investigated adherence to PrEP [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan additionalcitationids=\"CR81\" citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e] as did six qualitative studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e], while three studies examined continuous use [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Ten quantitative [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e] and two qualitative studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] assessed retention in care.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement\u003c/h2\u003e \u003cp\u003eAll quantitative studies investigating awareness of PrEP ascertained the outcome by asking whether participants \u0026ldquo;ever heard of\u0026rdquo; the method with the response provided as \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;. One study assessed FSW\u0026rsquo;s knowledge by estimating the relative importance index of different PrEP knowledge questions [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e] and another based on a score of \u0026ge;\u0026thinsp;50% using a knowledge assessment scale [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile most studies determined PrEP uptake by asking \u0026ldquo;ever use\u0026rdquo; with a \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; response, nine studies assessed in terms of newly initiating the prevention method [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]. Other nine studies assessed current or continuous use by asking whether participants were on PrEP [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e] and one study in terms of accessing PrEP services [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrEP adherence was measured in a variety of ways at different time points since initiation and duration of use. While two studies assessed using self-report and pill-count on dose adherence irrespective of PrEP initiation time [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], four studies used self-report [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e] one supporting this with a monthly pharmacy refill adherence [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. One study measured only a monthly pharmacy refill adherence [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. Three studies strictly defined self-reported adherence as reporting 100% use of prescribed dose [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e] and other two defined as the use of \u0026gt;\u0026thinsp;95% [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] and \u0026gt;\u0026thinsp;85% [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Two studies set pill count adherence at \u0026gt;\u0026thinsp;95% [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] and \u0026ge;\u0026thinsp;85% [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Two studies [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e] determined blood drug level (both taking\u0026thinsp;\u0026ge;\u0026thinsp;35.5 ng/mL TFV blood concentration as 100% weekly adherence), one of which additionally applying electronic monitoring of daily use [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRetention in care was assessed by all studies in terms of attending a range of follow-up clinic visits after PrEP initiation. While four studies [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e] measured the outcome at more than one point in time (ranging from first month to twelfth month), six [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e] measured at a specific point in time \u0026ndash; at first, second, sixth and twelfth month.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRisk of bias\u003c/h3\u003e\n\u003cp\u003eUsing the ROBINS-E, of 27 quantitative studies that performed statistical analyses on association between exposures and outcomes, five were assessed as having low overall risk of bias [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e] and four had some concerns [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. While eight studies had a high risk of bias [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e], ten had a very high risk of bias [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e] with four of these decided without the need for further assessment [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Most studies with the high risk and very high risk of bias were those assessing adherence and retention in care. The risk of bias assessment results are presented in the additional file (see Additional file 7).\u003c/p\u003e \u003cp\u003eThe majority of included qualitative studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e] addressed more than half of the ten quality domains specified by the JBI appraisal checklist, with one study scoring eight [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Five studies addressed half of the domains [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] and one study exploring adherence did not address any [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The details of quality assessment results are presented in the additional file (see Additional file 8).\u003c/p\u003e\n\u003ch3\u003eResults of individual studies\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative results\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eAwareness, acceptability and uptake\u003c/h2\u003e \u003cp\u003eThe level of PrEP awareness among FSWs ranged from 8% in a study from Tanzania [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] to 96% in Zambia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Slightly more than half (53%) of the studies reported an awareness level greater than 50% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. One study reported a PrEP knowledge level of 35% among those who were identified as aware of PrEP [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e] and another found 51% among all participating FSWs [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Among studies that investigated PrEP acceptability, the median ranged between 54% and 80% [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. The remaining studies reported willingness to use in more than 90% of FSWs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e] with the exception of one study from Nigeria which reported just 8% [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Most studies (39%) that investigated PrEP uptake reported \u0026lsquo;ever use\u0026rsquo; or recent initiation in more than 50% of FSWs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e], with one study reporting 82% [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. Notably, the level of uptake was less than 20% in the majority of studies that reported lower than 50% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. The proportion of current PrEP users ranged from 8% again in Tanzania [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] to 60% in Rwanda [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] with half of the studies reporting between 45% and 53% [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAdherence and retention in care\u003c/h2\u003e \u003cp\u003eThe prevalence of PrEP adherence greatly varied depending on precision of methods used for measurement. Studies that directly determined drug concentration in the blood found lower prevalence compared to those using electronic monitoring, self-report or a pill count method. One study reported a composite blood-drug-level adherence of just 34% combining results of fourteenth day as well as sixth, twelfth, eighteenth and twenty-fourth month adherence since PrEP initiation [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Another study using the same method found 42.6% and 21.7% adherence at third and sixth month, respectively [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. This same study used an electronic monitoring method and found a sharp decline from 80% at first month to 50% at second month [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. First month self-reported adherence, on the other hand, ranged from 43.3\u0026ndash;78% [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e] and showed a declining pattern [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]. Two studies reported a three-month self-reported adherence of 50% [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] and 66% [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] without specifying duration on PrEP while another study reported a one-month adherence of 61% [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Other two studies reported a one-month and three-month pill-count adherence of 48.3% [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] and 71% [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], setting adherence cut-off at \u0026gt;\u0026thinsp;95% and \u0026ge;\u0026thinsp;85% use of prescription, respectively. Two studies reported a monthly pharmacy-refill adherence of 67% [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and 73% [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e] without specifying PrEP duration.\u003c/p\u003e \u003cp\u003eDespite some exceptions, rates of retention in care consistently decreased over time following PrEP initiation. For example, one study reported a retention rate of 53% at the first month which declined to 33% at the fourth month and to just 9% at the twelfth month [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Similarly, two other studies reported a sharp drop over time; one reporting a decline from 92% at the first month to 86% at the sixth month and to 76% at the twelfth month [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] and the other an even steeper drop from 81% at the first month to 67% at the sixth month and to 53% at the twelfth month [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Another study reported that 80% of FSWs who initiated PrEP were retained in care at the sixth month, with 73% remaining at the twelfth month [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. Other studies reported rates of retention ranging from 41\u0026ndash;62% at the first month [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e] and as low as just 5% at the twelfth month [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]. Two studies, one from Uganda [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] and the other from Botswana [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e], reported considerably low rates of retention at the first (32%) and the sixth month (17%) of PrEP initiation respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with PrEP cascade components\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eAcceptability and uptake\u003c/h2\u003e \u003cp\u003eBehavioural characteristics that can increase the risk of HIV-infection were significantly associated with PrEP acceptability and uptake. While ever having been screened for or diagnosed with sexually transmitted infections (STIs) was associated with both acceptability [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e] and uptake [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e], an experience of recent unprotected sex, injecting drug use and being in a long-term relationship increased the odds of acceptability [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Similarly, FSWs who had more clients and engaged in sex work for longer period were more likely to accept [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e] and initiate [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] although some contradictions exist regarding the influence of duration of sex work on acceptability [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe likelihood of acceptability [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] and uptake [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] was also reported to be associated with perceived social support from peers and family despite some contrasting findings regarding support from close friends and uptake [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although one study uniquely reported a positive association between sex-work stigma from family and PrEP uptake [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], another study found an increase in the likelihood of acceptability with a decrease in stigma [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. FSWs were more likely to accept PrEP when they were well-aware of it and perceived ease of access [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e], and to initiate when they possessed a positive attitude towards the method [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Increasing age (although some exceptions [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]) and having more children respectively increased acceptability [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e] and uptake [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e], and entry into sex work at younger age (especially below 25 years) was associated with a higher likelihood of acceptability [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eAdherence, current use and retention in care\u003c/h2\u003e \u003cp\u003eMost factors that were associated with the preceding cascade elements essentially appeared to persist in influencing adherence, current use and retention in care. Accordingly, behavioural characteristics related to HIV risk perception were significantly associated with all the three outcomes. Having a long-term partnership, and sex with an HIV-positive partner were associated with current use [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Having a greater number of clients increased the likelihood of both adherence [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] and retention in care [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]; and FSWs were more likely to adhere when they engaged in sex work in more than one location (e.g., both urban and rural settings), experienced STI and used post-exposure prophylaxis (PEP) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], and to continue using when they encountered physical violence and wholly perceived HIV risk due to sex work [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. However, contrasting findings exist regarding the influence of duration of engagement in sex work on current use [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAttitude towards PrEP and intention to use were two other behavioural constructs reported to influence adherence, which was significantly higher when FSWs had a positive attitude towards PrEP and its packaging [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] but lower when they lacked an intention to consistently use it [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. On the other hand, while self-efficacy to consistently use condom during sex was also reflected on adherence [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and retention in care [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], PrEP knowledge was linked with continuous use [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological conditions such as mental distress and experience of emotional violence were negatively associated with current use [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] and retention in care [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] although one study found a positive association between experience of depression and adherence [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The effect of social factors on PrEP use was reported as quite mixed. While living with a family member rather than a friend significantly enhanced adherence [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], living with someone at all discouraged retention in care [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Possibly reflecting the latter case, enacted social stigma was significantly associated with reduced retention in care [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs they were to accept and initiate PrEP, older FSWs (\u0026gt;\u0026thinsp;25 years of age) were also more likely to adhere [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e] and be retained in care [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e] despite some exceptions regarding the latter [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. The chance of retention in care was high when FSWs expressed a desire to have more children [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Being engaged in other jobs in addition to sex work and attaining a higher level of education were associated with both increased adherence and retention in care [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e], and urban residence decreased retention in care [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile use of a reminder to medication schedule was associated with increased adherence [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], being on a long-term contraceptive was linked with reduced adherence [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Adherence also showed a decreasing pattern as follow-up time increased [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e], but retention in care increased when FSWs perceived good treatment by health care providers [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eQualitative findings\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eAcceptability\u003c/h2\u003e \u003cp\u003eThe most frequent theme emerging from the studies as a barrier to PrEP acceptability was related to perceived pill-burden and drug-side effects, which seemed to be difficult for FSWs to accept while being apparently healthy [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. As was the case in the quantitative findings, perceptions of social stigma (especially among clients) was the second most common barrier to PrEP acceptability, which was often associated with the similarity between PrEP and ARV drugs [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. That is, FSWs feared that others would assume they were HIV-infected \u0026ndash; an already greatly stigmatized condition in SSA. Other reported barriers included a lack of adequate knowledge about PrEP [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] and perceived low self-efficacy to consistently use due to the mobile nature of sex work and frequent alcohol use [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFeaturing prominently in the qualitative studies (also a prominent factor in quantitative studies), was a perceived high HIV risk due to inconsistent condom use that was attributed to various factors including partner/client refusal and violence. Being engaged in a long-term relationship, experience of condom burst, needing more money and/or substance misuse were found to be important facilitators in all studies that explored acceptability [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. Similarly, intention to self-care (maintenance of health in the face of risky (sex) work) appeared to facilitate PrEP acceptability [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eUptake\u003c/h2\u003e \u003cp\u003eNearly all of the perceived barriers to and facilitators of PrEP acceptability also appeared to influence the actual uptake. Social stigma (from clients, peers, friends, family and the society at large) related to misconceptions of PrEP as an HIV treatment rather than a prevention method was the most frequently reported barrier to uptake [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. A related barrier was a general lack of awareness among FSWs about the method [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Some studies reported the existence of doubt among FSWs about how to use PrEP along with condom and its additional benefits [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Reluctance to initiate PrEP was also due to its use essentially serving as a disclosure of sex work, a practice that is highly stigmatized in many settings [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother persistent behavioural challenge to the PrEP continuum and uptake was perceived drug side-effects which FSWs often found it difficult to accept while being in a state of complete health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Structural factors related to the opportunity cost of service access including transportation cost and long waiting times as well as providers\u0026rsquo; hesitance to make timely prescriptions (partly attributable to having limited skills) also contributed to low PrEP uptake [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. FSWs tended to be more likely to start PrEP when it was provided in a non-judgmental user-friendly way, often using peers [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFSW\u0026rsquo;s perceptions of the high risk of HIV-infection in the face of unsafe sex-work environments enhanced PrEP uptake across included studies [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Another common facilitator of uptake was that of FSW\u0026rsquo;s sense of self-care and responsibility for others (e.g., children), as well as having future goals and positive aspirations [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. The experience of obtaining a negative HIV test when they did not expect it was a motivating factor for FSWs to initiate PrEP [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. FSWs were also motivated to initiate PrEP when they understood that it is a self-controlled prevention method without the need for client approval [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Lack of social support adversely affected uptake [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], but FSWs were often found to be motivated to initiate when they received support from peers, friends and family as well as community mobilisers [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAdherence and retention in care\u003c/h2\u003e \u003cp\u003eA prominent theme affecting PrEP adherence in FSWs was forgetting to take the medication, frequently associated with the nature of sex-work (e.g., night work, mobility of sex workplace and substance misuse) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Experiences of drug-side effects (especially in the early phase of treatment) and pill-burden were commonly reported as influencing both daily use [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] and continuation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePerceptions of social stigma continued playing a crucial role in the care continuum by reducing FSW\u0026rsquo;s capacity for daily [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] as well as continuous PrEP use [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. This was due to the association between PrEP and HIV-infection and sex-work \u0026ndash; both of which remain highly stigmatized in SSA society. Social stigma was also associated with reduced social support from peers and family, which was an important facilitator of adherence [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] and retention in care [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Consistent with the quantitative findings, FSWs were found to be more PrEP compliant when they were able to use individual strategies to manage their medication schedule (e.g., setting alarms and linking medication time with daily routines) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHIV-negative test results subsequent to PrEP initiation tended to motivate FSWs to comply with medication schedules [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] but they were discouraged to continuously use when they had a perception of low HIV risk [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. In terms of service delivery, while limited counselling availability, long clinic waiting time and unresponsive work hours discouraged retention [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e], private and non-judgmental delivery models encouraged both initiation and continued PrEP use [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur review aimed to synthesize the evidence for contextual factors affecting PrEP care continuum among FSWs in SSA \u0026ndash; a population group bearing a high burden of the epidemic in the region [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Synthesis of such factors facilitates the development of evidence-based interventions that can enhance the scale-up of the programme to increase its impact on the epidemic \u0026ndash; as part of a combination prevention approach including biomedical, behavioural and structural interventions for high risk population groups such as FSWs [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is large variation in the FSW\u0026rsquo;s level of awareness about PrEP in SSA, which reflects the impact of educational efforts in some settings but highlights gaps in such efforts in other areas. This has also been observed across settings within the same country. A previous global review [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] similarly reported a wide range of awareness level across countries, which was associated with access to various information sources such as participation in PrEP research, peer associations, social media and other mainstream media.\u003c/p\u003e \u003cp\u003eOur review identified a generally high level of PrEP acceptability among FSWs but only moderate uptake, consistent with previous reviews [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, considerably low levels of acceptability and uptake have been reported in some settings, and the overall level of current use was lower relative to uptake, suggesting high discontinuation rates. In all included studies, regardless of the measurement methods, adherence to PrEP was found to be lower than the \u0026ldquo;protection-effective adherence\u0026rdquo; set by clinical trials (i.e., \u0026gt;\u0026thinsp;85%) [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e] and showed a sharp decline over time, which is similar to previous review findings [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A similar pattern was observed for retention in care in the majority of studies, although high retention rates were maintained in some settings.\u003c/p\u003e \u003cp\u003eWhile a limited awareness in association with the novelty of the method to some settings critically influenced the care continuum, especially the earlier stages, a number of individual, social and structural level factors were reported by the reviewed studies that affected each component.\u003c/p\u003e \u003cp\u003eIt emerged from the review that the entire care continuum is highly dependent on FSW\u0026rsquo;s perception of elevated HIV risk, perceptions formed through experiencing or anticipating unsafe sexual encounters. The association between individual risk perceptions and high uptake, and consistent and continuous use has been reported in previous reviews [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This suggests the importance of continuous risk assessment and attention to the social drivers of HIV perceived vulnerability within the context of SSA [\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e]. This needs to be supported by ongoing HIV testing as negative test results subsequent to PrEP initiation appeared to facilitate the care continuum in our review. HIV self-testing is a highly recommended approach in this regard as it complements existing testing strategies for PrEP and is preferred for convenience, privacy and self-managed care [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe PrEP care continuum among FSWs in SSA is more likely to be effective when the users perceived responsibility for current circumstances and held life aspirations in the future. This was demonstrated by the fact that motivation of health maintenance was driven by the responsibility for a family, or the desire to have a family, and the belief that sex work is only temporary primarily performed because of a lack of alternative livelihood [\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]. This suggests that life skills training may enhance FSW\u0026rsquo;s capacity to make informed decisions in addition to identification of an individual high risk season to facilitate targeted PrEP use [\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePerceived social support from significant others and other close ones including family, peers and friends was found to be critical in enhancing the PrEP care continuum among FSWs. Beyond being an important source of material and emotional help which could reduce mental distress and enhance self-efficacy, such support may also serve as an essential source of information encouraging informed decision making. Correspondingly, perceived social stigma from such close ones as well as the larger society including clients \u0026ndash; usually arising from the association between HIV infection and sex work with PrEP \u0026ndash; has been identified as an important PrEP care continuum barrier. Community mobilization and engagement in the PrEP programme is strongly suggested to create awareness and hence increase social support while reducing stigma [\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e]. Peer initiatives such as sex-workers programmes are very effective in this regard and should be supported by social marketing of the prevention method [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs previous reviews have found [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e], there is a high likelihood of improving the PrEP care continuum among FSWs when services are provided in a more accessible and non-judgmental way. As poverty is a major driver of engagement in sex work in the context of SSA [\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e], opportunity costs such as transportation to health care facilities and long-waiting times appear to be prominent structural barriers. A previous review in SSA [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] identified a higher PrEP uptake and lower retention in care when PrEP service was delivered through a health facility-based model compared to community-based model. A hesitancy of providers to prescribe PrEP formed a further structural barrier in our review. This could potentially be attributed to higher priority being given to already infected individuals but may also be due limited skills and knowledge in PrEP, which remains a challenge for facility-based models of service provision in SSA. WHO recommends a differentiated and comprehensive PrEP delivery approach that adapts services to the needs and preferences of the target population [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]. Health staff training along with engagement of FSWs in service delivery may facilitate a possible combination of different delivery models which are compatible to different contexts [\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDrug side effects and the burden of daily use are proposed by FSWs as barriers to initiating and continuing PrEP use. Although the side effects might be potentially overstated prior to initiation, there have been many reports that PrEP drugs cause temporary discomfort, particularly soon after initiation, which significantly affects adherence and retention in care [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The frequency of use required for oral PrEP coupled with the absence of disease symptoms (i.e., inherently, PrEP is deployed in those in relatively good health) is a substantial challenge to maintaining the care continuum. Proper counselling of potential side effects and their management methods is suggested especially during initiation. Efforts to ensure the availability of long-acting injectable modalities are also the preferred options by FSWs, as this avoids having to remember doses each day, which can be quite challenging given the highly mobile nature of sex work within the context of SSA [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur review findings are limited by the fact that research on PrEP among FSWs in SSA has predominantly concentrated in the eastern and southern part of the region and only few studies have so far been conducted in the central and western countries. Although the former represents a substantial burden of the HIV epidemic among FSWs, the latter also holds high prevalences contributing significantly to the global burden of the disease [\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e], and requires further research.\u003c/p\u003e \u003cp\u003eSome outcomes such as awareness and acceptability were not assessed in depth by most of the included studies i.e., usually on the basis of \u0026lsquo;Yes\u0026rsquo; or \u0026lsquo;No\u0026rsquo; response to a single question. This might have led to an overestimate of results overall and is demonstrated by lower estimates reported by studies undertaking more in-depth analysis. Further exploration is required to identify contextual barriers to retention in care as this was undertaken by only a limited number of qualitative studies. Although all included studies defined adherence thresholds as using\u0026thinsp;\u0026gt;\u0026thinsp;85% of prescribed dose, which is set as a \u0026ldquo;prevention effective\u0026rdquo; adherence by clinical trials, variation in the threshold along with the differences in the precision of measurements taken poses a problem in comparing results across studies.\u003c/p\u003e \u003cp\u003eThat only a third of the included quantitative studies were assessed as having a \u0026lsquo;low risk\u0026rsquo; or \u0026lsquo;some concerns\u0026rsquo; of bias means that the level of certainty of evidence regarding associations between the exposure variables and outcomes is reduced. This is especially true of adherence and retention in care studies, which account for a large proportion of the \u0026lsquo;very high\u0026rsquo; and \u0026lsquo;high risk\u0026rsquo; of bias at assessment. However, the consistency of the evidence on the influence of most of the factors identified and the congruence between quantitative and qualitative findings indicates the pervasiveness of the issues in the SSA context and have critical public health implications for policy and practice.\u003c/p\u003e \u003cp\u003eScreening of study eligibility, risk of bias assessment and data extraction by a single author might have introduced some error although verification of the results by one of the co-authors reduces the bias. Due to setting-related resource limitations, our search strategy included only four databases and might not have been sufficiently exhaustive to avoid publication bias, and we were unable to access full texts of three potentially eligible studies, although an attempt was made to search for grey literature. The influence of limiting our review to only English studies may also have systematically excluded some studies, although the probability of publication in other languages in SSA is likely to be low as observed in the retrieved records.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings underscore the importance of adhering to best practices in order to increase awareness about PrEP among FSWs in SSA and to translate the high acceptability into uptake, maintain optimal adherence and retention in care. Continuous risk assessment supported by self-testing and life skills training among FSWs is required to ensure improved PrEP care continuum. At a societal level, community education and engagement efforts are needed to enhance social support and reduce stigma. Finally, the PrEP care continuum can also be improved through implementation of differentiated and user-centred delivery approaches and product modalities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset supporting the conclusions of this article is included within the article and its additional files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTGF developed the search strategy; conducted searching, screening of the articles, data extraction and analysis; drafted the manuscript. ERM undertook subsequent revisions of the manuscript. TLE verified included studies, data extracted, and risk of bias assessment results, and reviewed the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge authors of the primary studies.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKerrigan D, Wirtz A, Baral S, Decke M, Murray L, Poteat T, et al. The global HIV epidemics among sex workers. Washington, DC: World Bank; 2013.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries: recommendations for a public health approach. 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AIDS Behav. 2012;16(4):920-33; https://doi.org/10.1007/s10461-011-9985-z. \u003c/li\u003e\n\u003cli\u003ePinto RM, Berringer KR, Melendez R, Mmeje O. Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature. AIDS Behav. 2018;22(11):3681-91; https://doi.org/10.1007/s10461-018-2184-4.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. HIV statistics, globally and by WHO region, 2024. Geneva, Switzerland: WHO; 2024.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"systematic-reviews","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sysr","sideBox":"Learn more about [Systematic Reviews](http://systematicreviewsjournal.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/sysr/default.aspx","title":"Systematic Reviews","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pre-exposure prophylaxis, care continuum, factors, female sex workers, sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-6671884/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6671884/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eFemale sex workers (FSWs) are disproportionately affected by the HIV epidemic in sub-Saharan Africa (SSA). Pre-exposure prophylaxis (PrEP) is a relatively novel approach in SSA recommended to complement the existing combination prevention methods for such high risk populations. The PrEP care continuum including awareness, acceptability, uptake, adherence and retention in care is affected by varying contextual factors in the region. Our review aimed to synthesize existing evidence regarding such factors in order to suggest evidence-based interventions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eWe conducted a systematic review of observational quantitative studies and qualitative studies assessing factors affecting one or more components of the continuum. We searched Medline, PubMed, CINAHL and Web of Science databases on 12 June 2024, and grey literature through Google Scholar on 23 December 2024. We used the Cochrane “Risk of bias” tool for non-randomised studies to assess risk of bias in quantitative studies, and the JBI Critical Appraisal Checklist for Qualitative Research in qualitative studies. Given a great methodological heterogeneity among included studies, we provided a narrative synthesis of both quantitative and qualitative findings. This review is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD420250650765).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eOf 904 articles retrieved from all sources, 53 were eligible for inclusion in the review. Among these, 35 studies were quantitative, 15 qualitative and the remaining three were mixed-methods studies. Fourteen studies assessed level of awareness/knowledge about PrEP and the results ranged from 8% to 96%. Level of PrEP acceptability was assessed by twelve studies and was found to be generally high (\u0026gt;90% in most cases) whereas a relatively moderate uptake was reported by eighteen studies (\u0026gt;50% in most cases) and lower current use (generally \u0026lt;50%) as reported by six studies.\u003c/p\u003e\n\u003cp\u003eTen studies reported on level of PrEP adherence and in all cases it was lower than “the protective level adherence” (i.e. \u0026gt;85%) and showed a decreasing pattern as follow-up time increased. Retention in care was assessed by nine studies in which it varied greatly across studies (from 32% to 92% at first month) and declined sharply over time. In addition to limited awareness due to the novelty of PrEP, factors including perceptions of HIV risk and responsibility and life aspiration; social support and stigma; accessibility of non-judgmental services; and concerns regarding drug side-effects and pill burden were reported as determinants of PrEP continuum.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e: \u003c/strong\u003eOur findings suggest that the PrEP care continuum among FSWs in SSA can be improved through adapting best practices and implementation of differentiated and user-centred delivery approaches and product modalities supported by continuous risk assessment and community engagement.\u003c/p\u003e","manuscriptTitle":"HIV pre-exposure prophylaxis care continuum among female sex-workers in sub-Saharan Africa: a systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 09:33:36","doi":"10.21203/rs.3.rs-6671884/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2025-12-05T09:54:30+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-06-17T10:55:34+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T10:28:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-12T03:35:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Systematic Reviews","date":"2025-05-21T10:15:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"systematic-reviews","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sysr","sideBox":"Learn more about [Systematic Reviews](http://systematicreviewsjournal.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/sysr/default.aspx","title":"Systematic Reviews","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"588f88e5-c868-4c7f-b0a4-9f6a1b3589f1","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-07T09:40:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-25 09:33:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6671884","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6671884","identity":"rs-6671884","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}