Twenty years’ worth of surveys suggest that nearly one in 10 sexually active men in 35 countries in sub-Saharan Africa have been clients of sex workers, and are about 50% more likely to be living with human immunodeficiency virus (HIV).
Sex workers represent one of several key populations at higher risk of acquiring HIV. However, while their clients also play a central role in HIV transmission networks, epidemiological research and HIV prevention efforts have often neglected men who pay for sex. Instead, sex workers have been assigned greater responsibility and burden for prevention of HIV transmission.
These findings were presented by Caroline Hodgins of McGill University, Canada, and colleagues, in the open-access journal PLOS Medicine.
To better understand the dynamics of HIV in transactional sex and identify new opportunities for prevention, Hodgins and colleagues conducted a meta-analysis of data from 87 surveys of men living in sub-Saharan Africa. The surveys were conducted by other researchers and organisations between 2000 and 2020, and included more than 368,000 participants.
Statistical analysis of the survey results showed that about 8% of participants who were sexually active had ever paid for sex, and these men were 50% more likely to be living with HIV than men who reported never paying for sex. Of men who were clients of sex workers between 2010 and 2020, 68% reported using a condom during their most recent paid sex encounter, though this percentage had been lower in the previous decade.
Based on these findings, the authors suggest that male clients of sex workers should be considered a key population that is at high risk of HIV and in need of increased prevention efforts. Such efforts could include improved access to HIV testing and initiatives to encourage condom use.
Future research could help confirm and expand on these findings, such as by improving the confidentiality of surveys and collecting more data on the use of HIV treatment.
“Men who pay for sex should be recognised as a priority population for HIV prevention. These data are striking and call for tailored HIV services for men paying for sex in this region. Identifying HIV infected men, initiating and retaining them on ART is key for reducing new HIV infections recorded in the region each year,” said Dr Shannon Hader, deputy executive director programmes, UNAIDS, Switzerland.
Study details
Population sizes, HIV prevalence, and HIV prevention among men who paid for sex in sub-Saharan Africa (2000–2020): A meta-analysis of 87 population-based surveys
Caroline Hodgins, James Stannah, Salome Kuchukhidze, Lycias Zembe, Jeffrey W. Eaton, Marie-Claude Boily, Mathieu Maheu-Giroux.
Published in PLOS Medicine on 25 January 2022
Abstract
Background
Key populations, including sex workers, are at high risk of HIV acquisition and transmission. Men who pay for sex can contribute to HIV transmission through sexual relationships with both sex workers and their other partners. To characterise the population of men who pay for sex in sub-Saharan Africa (SSA), we analysed population size, HIV prevalence, and use of HIV prevention and treatment.
Methods and findings
We performed random-effects meta-analyses of population-based surveys conducted in SSA from 2000 to 2020 with information on paid sex by men. We extracted population size, lifetime number of sexual partners, condom use, HIV prevalence, HIV testing, antiretroviral (ARV) use, and viral load suppression (VLS) among sexually active men. We pooled by regions and time periods, and assessed time trends using meta-regressions. We included 87 surveys, totalling over 368,000 male respondents (15–54 years old), from 35 countries representing 95% of men in SSA. Eight percent (95% CI 6%–10%; number of surveys [Ns] = 87) of sexually active men reported ever paying for sex. Condom use at last paid sex increased over time and was 68% (95% CI 64%–71%; Ns = 61) in surveys conducted from 2010 onwards. Men who paid for sex had higher HIV prevalence (prevalence ratio [PR] = 1.50; 95% CI 1.31–1.72; Ns = 52) and were more likely to have ever tested for HIV (PR = 1.14; 95% CI 1.06–1.24; Ns = 81) than men who had not paid for sex. Men living with HIV who paid for sex had similar levels of lifetime HIV testing (PR = 0.96; 95% CI 0.88–1.05; Ns = 18), ARV use (PR = 1.01; 95% CI 0.86–1.18; Ns = 8), and VLS (PR = 1.00; 95% CI 0.86–1.17; Ns = 9) as those living with HIV who did not pay for sex. Study limitations include a reliance on self-report of sensitive behaviours and the small number of surveys with information on ARV use and VLS.
Conclusions
Paying for sex is prevalent, and men who ever paid for sex were 50% more likely to be living with HIV compared with other men in these 35 countries. Further prevention efforts are needed for this vulnerable population, including improved access to HIV testing and condom use initiatives. Men who pay for sex should be recognised as a priority population for HIV prevention.
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