Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2020 Sep 4;15(9):e0238639.
doi: 10.1371/journal.pone.0238639. eCollection 2020.

The burden of HIV infection among men who purchase sex in low- and middle-income countries - a systematic review and meta-analysis

Luh Putu Lila Wulandari  1   2 , Rebecca Guy  1 , John Kaldor  1
Affiliations
Meta-Analysis

The burden of HIV infection among men who purchase sex in low- and middle-income countries - a systematic review and meta-analysis

Luh Putu Lila Wulandari et al. PLoS One. .

Abstract

Background: Since the start of the HIV epidemic, transactional sexual relationships have been considered to present a high risk of HIV transmission to both the client and the person offering the sexual service. However, prevention research and programs have focused predominantly on sex workers rather than on their clients, who are generally men. To support effective and targeted interventions, we undertook a systematic review and meta-analysis of the evidence of the prevalence of HIV infection among men who purchase sex (MWPS) in low- and middle-income countries (LMICs), and the association between HIV infection and purchase of sex.

Methods: We included articles that reported from LMICs on the prevalence of HIV in MWPS and those that reported on HIV prevalence among both MWPS and non-MWPS in the same study, or any information which allowed calculation of the prevalence. We defined MWPS as heterosexual males (not men who purchase sex or individuals of other sexual orientation) who purchased sex mostly from women (and not men), or who have had sexual contact with female sex workers (FSWs). We searched Medline, Global Health, Scopus, Embase and Cinahl for articles published up until 1 March 2020. Meta-analysis was conducted using a random effects model to estimate the pooled HIV prevalence and the relative risk (RR) of HIV infection associated with purchasing sex.

Results: Of 34862 studies screened, we included 44 studies (59515 men, 47753 MWPS) from 21 countries. The pooled HIV prevalence among MWPS was 5% (95%CI: 4%-6%; I2 = 95.9%, p < 0.001). The pooled HIV prevalence calculated from studies that reported data collected pre-2001 was highest, i.e. 10% (95% CI: 6%-14%; I2 = 91.2%, p < 0.001), compared to studies whose data was collected between 2001-2010, i.e. 4% (95%CI: 2%-6%; I2 = 96.6%, p < 0.001), and from 2011 and beyond, i.e. 3% (95% CI: 2%-5%; I2 = 94.3%, p < 0.001). For studies which included comparisons of HIV infection among MWPS and non-MWPS, the relative risk of HIV infection was consistently higher among MWPS than among non-MWPS within the same study, with the overall pooled relative risk of 1.95 (95%CI: 1.56-2.44; I2 = 84.3%, p < 0.001), and 2.85 (95%CI: 1.04-7.76; I2 = 86.5%, p < 0.001) for more recent studies.

Conclusions: This review represents the first comprehensive assessment of the burden of HIV among MWPS in LMICs. We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association between purchasing sex and HIV prevalence. Despite a reduction over time in prevalence, these data highlight that MWPS need better access to HIV preventive interventions.

PubMed Disclaimer

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. A flow diagram of the search and paper selection process.
Fig 2
Fig 2. Meta-analysis of HIV prevalence among MWPS in LMICs by data collection period.
ES: Estimated prevalence, n: Number of HIV positive, N: Number of samples.
Fig 3
Fig 3. Meta-analysis of HIV prevalence among MWPS in LMICs by region.
ES: Estimated prevalence, n: Number of HIV positive, N: Number of samples.
Fig 4
Fig 4. Meta-analysis of HIV risk in MWPS versus non-MWPS in LMICs by data collection period.
RR: Relative risk, n: Number of HIV positive, N: Number of samples.
Fig 5
Fig 5. Meta-analysis of HIV risk in MWPS versus non-MWPS in LMICs by region.
RR: Relative risk, n: Number of HIV positive, N: Number of samples.
See this image and copyright information in PMC

References

    1. Oldenburg CE, Perez-Brumer AG, Reisner SL, Mattie J, Barnighausen T, Mayer KH, et al. Global burden of HIV among men who engage in transactional sex: a systematic review and meta-analysis. PLoS One. 2014;9(7):e103549 10.1371/journal.pone.0103549 - DOI - PMC - PubMed
    1. World Health Organization. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations– 2016 update. Geneva: World Health Organization; 2016.
    1. Chersich MF, Luchters S, Ntaganira I, Gerbase A, Lo Y-R, Scorgie F, et al. Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services. J Int AIDS Soc. 2013;16(1):17980. - PMC - PubMed
    1. Ghimire L, Smith WCS, van Teijlingen ER, Dahal R, Luitel NP. Reasons for non- use of condoms and self- efficacy among female sex workers: a qualitative study in Nepal. BMC Womens Health. 2011;11(1):42. - PMC - PubMed
    1. Huang Y, Maman S, Pan S. Understanding the diversity of male clients of sex workers in China and the implications for HIV prevention programmes. Global Public Health. 2012;7(5):509–21. 10.1080/17441692.2012.657663 - DOI - PubMed