Twenty years’ worth of surveys suggest that nearly one in ten sexually active men in 35 countries in sub-Saharan Africa have been clients of sex workers, and these men are about 50% more likely to be living with human immunodeficiency virus (HIV). Caroline Hodgins of McGill University, Canada, and colleagues present these findings in the open-access journal PLOS Medicine.
Sex workers represent one of several key populations who are 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.
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 organizations 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.
The authors add, “We found that men who have paid for sex in sub-Saharan Africa are 50% more likely to be living with HIV compared to other men. Men who pay for sex should be recognized 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,” says Dr. Shannon Hader, Deputy Executive Director Programmes, UNAIDS, Switzerland.