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 characterize the population of men who pay for sex in sub-Saharan Africa (SSA), we analyzed 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, totaling 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 behaviors and the small number of surveys with information on ARV use and VLS.
Paying for sex is prevalent, and men who ever paid for sex were 50% more likely to be living with HIV compared to 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 recognized as a priority population for HIV prevention.
Why was this study done?
- Key populations, including sex workers, are at a high risk of HIV acquisition and transmission.
- Clients of sex workers often have central roles in HIV transmission networks: they have sexual contacts with both sex workers and other partners.
- Despite their vulnerability to HIV acquisition and transmission, male clients of sex workers are not formally recognized as a key population.
- Characterizing HIV epidemiology among men who pay for sex is important to understand their HIV burden and, ultimately, develop appropriate interventions.
What did the researchers do and find?
- We performed meta-analyses of 87 population-based surveys from sub-Saharan Africa (2000–2020) to estimate pooled proportions of men who ever paid for sex, condom use during paid sex, HIV prevalence, and HIV prevention and treatment outcomes.
- Up to 1 in 10 sexually active men in these surveys reported ever paying for sex, and condom use during paid sex has remained suboptimal, at 68% over the last decade.
- Men living in urban areas were more likely than those in rural areas to report ever paying for sex, and younger men (15–24 years) were more likely to have paid for sex in the past 12 months.
- HIV prevalence was higher among men who ever paid for sex as compared to those who did not.
What do these findings mean?
- Men who pay for sex continue to constitute a distinct population subgroup at high risk of HIV acquisition and transmission. They should be recognized as a priority population for HIV prevention.
- Without increased HIV prevention efforts among clients of sex workers, including improved access to HIV testing and condom use initiatives, female sex workers and their clients will continue to be at risk of HIV acquisition.