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

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 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.

Conclusions: 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.

Fig 1. Surveys with questions about ever paying for sex, by country and year, 2000–2020.

Points represent population-based surveys conducted in sub-Saharan Africa from 2000 to 2020 and asking men about ever paying for sex. Circles represent surveys with data on HIV testing, while triangles represent surveys without data on HIV testing. Filled in points represent surveys that include HIV biomarker testing, while empty points represent surveys that did not have biomarker testing. AIS, AIDS Indicator Survey; DHS, Demographic and Health Surveys; KAIS, Kenya AIDS Indicator Survey; PHIA, Population-based HIV Impact Assessment; SABSSM, South African National HIV Prevalence, Incidence, Behaviour and Communication Survey.

Fig 2. Flowchart of population-based survey inclusion in each analysis.

A total of 226 population-based surveys conducted in sub-Saharan Africa from 2000 to 2020 were reviewed, and 87 were identified as having information on paid sex ever among men. Surveys were included in each analysis based on availability of relevant information.

Fig 3. Forest plots of proportions of sexually active men who ever paid for sex.

Data from 87 population-based surveys (78 DHS/AISs, 6 PHIAs, 2 SABSSMs, 1 KAIS) were collected and meta-analyses conducted to determine the proportion of men who have ever paid for sex. Pooled proportions were calculated for each region for both post-2010 (2010–2020) and pre-2010 (2000–2009) surveys, and overall. AIS, AIDS Indicator Survey; DHS, Demographic and Health Surveys; DRC, Democratic Republic of the Congo; KAIS, Kenya AIDS Indicator Survey; PHIA, Population-based HIV Impact Assessment; SABSSM, South African National HIV Prevalence, Incidence, Behaviour and Communication Survey.

Fig 4. Pooled estimates of HIV prevalence, condom use at last paid sex, HIV testing history, antiretroviral use, and viral load suppression among men who paid for sex, overall and stratified by sub-Saharan Africa regions.

Meta-analysis was performed for each outcome, and pooled proportions were calculated by region and overall. Analyses for HIV prevalence and HIV testing history were standardized by age and urban/rural residence type. PLHIV, people living with HIV.

Fig 5. Forest plot of standardized HIV prevalence ratios for men who have ever paid for sex compared to men who have never paid for sex.

HIV biomarker data from 52 population-based surveys were collected and meta-analyses conducted to determine HIV prevalence ratios for men who have ever paid for sex compared to men who have not. Prevalence ratios are standardized by age and urban/rural residence type. Pooled prevalence ratios were calculated for each region and overall. DHS, Demographic and Health Surveys; DRC, Democratic Republic of the Congo; PHIA, Population-based HIV Impact Assessment; PLHIV, people living with HIV.