Conclusion
Up to 1 in 10 men report ever paying for sex in SSA. To more accurately determine population sizes of men who pay for sex, improved confidential methods should be employed. Compared to those who have never paid for sex, men who have paid for sex have over double the lifetime number of partners, are more likely to be living with HIV, and, despite higher testing, could be less likely to know their status in some regions. Condom use initiatives and improved access to HIV testing campaigns are required to prevent HIV transmission from clients to sex workers and to their other sexual partners. These results suggest that men who pay for sex continue to constitute a distinct population subgroup at high risk of HIV acquisition and transmission, and that they should be recognized as a priority population for HIV prevention.
Supporting information
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Additional information on the surveys, detailed forest plots, and complementary statistical analyses.
Table A: List of surveys considered and justifications for exclusion. Table B: Characteristics of population-based surveys conducted between 2000 and 2020 with available microdata included in analyses. Table C: Number of surveys, pooled estimates, confidence intervals, prediction intervals, and I2 values by region and overall for each outcome. Table D: Pooled estimates, confidence intervals, prediction intervals, and I2 for 2000–2009 and 2010–2020 for prevalence of paying for sex, condom use at last paid sex, and HIV prevalence and testing among men who have paid for sex. Table E: Results of univariate meta-regression for survey year. Table F: Pooled estimates, confidence intervals, prediction intervals, and I2 values for prevalence of paying for sex ever and in the past 12 months by urban/rural residence type. Table G: Pooled estimates, confidence intervals, prediction intervals, and I2 values for prevalence of paying for sex ever and in the past 12 months by age groups. Fig A: Flow charts of “HIV testing history” and “men who have ever paid for sex.” Fig B: Men ever paying for sex over time, by country. The proportion of sexually active men reporting ever paying for sex was calculated for 87 population-based surveys and plotted over time for countries with 3 or more surveys. Fig C: Bar graph of standardized mean lifetime number of sex partners for men who have paid for sex compared to men who have not, by survey. Fig D: Forest plot of proportion of men who paid for sex who reported condom use at last paid sex. Fig E: Condom use at last paid sex over time, by country. Fig F: Forest plot of standardized HIV prevalence for men who have paid for sex. Data from 52 population-based surveys was collected and meta-analysis conducted to determine HIV prevalence among men who reported having paid for sex. Prevalence is standardized by age and urban/ rural residence type. Proportions were pooled by region and overall. Fig G: Forest plot of standardized prevalence ratios for HIV testing ever among men who have paid for sex compared to men who have not. Fig H: Forest plot of standardized prevalence ratios for HIV testing in the last 12 months among men who have paid for sex compared to men who have not. Fig I: Forest plot of standardized prevalence ratios for HIV testing ever among men living with HIV who have paid for sex compared to men who have not. Fig J: Forest plot of prevalence ratios of antiretroviral use among men living with HIV who have paid for sex compared to men who have not. Fig K: Forest plot of prevalence ratios of viral load suppression among men living with HIV who have paid for sex compared to men who have not.