Male clients of sex workers in sub-Saharan Africa 50% more likely to be living with HIV than other men

One in 12 sexually active men in sub-Saharan Africa have ever paid for sex and were 50% more likely to be living with HIV compared to men who did not pay for sex, a study recently published in PLOS Medicine has found. The research, which analysed population-based surveys from 35 countries also found that from 2010 to 2020, only 68% of men reported using a condom during their last paid sex encounter, and younger men were more likely to have had paid for sex in the past 12 months.

Clients of sex workers are highly vulnerable to HIV acquisition and transmission through sexual relationships with both sex workers and their other partners. But despite their vulnerability, they are not formally recognised as a key population by UNAIDS. To characterise the population of men who pay for sex in sub-Saharan Africa, Dr Caroline Hodgins of McGill University, Canada, and colleagues analysed 87 population-based surveys conducted from 2000 to 2020 that collected information on paid sex. These surveys included 368,263 sexually active male respondents aged 15 to 54 years from 35 countries. Together, these 35 countries represent 95% of men in sub-Saharan Africa.

Surveys generally asked about ever paying for sex, or doing so in the past 12 months. Most of the surveys didn’t specify the gender of sex workers.

The proportion of sexually active men who reported ever paying for sex in sub-Saharan Africa was 8% and they had an average of 12 lifetime sexual partners. Younger men (15–24 years) were more likely to report paying for sex in the past 12 months (5%) than those aged 35–54 years (2%), while men living in urban areas were more likely to report ever paying for sex (10%) than those from rural areas (7%).

HIV prevalence among men who paid for sex was 5%. Men who paid for sex were more likely to be living with HIV than men who did not pay for sex in all four regions of sub-Saharan Africa. The prevalence ratio among men who paid for sex and those who did not was 1.50 (that is, men who paid for sex were at 50% greater risk of HIV than other men).

Among men who reported paying for sex in the past year, 62% used a condom the last time they paid for sex. Condom use at last paid sex was higher for surveys conducted from 2010 onwards (68%) than in surveys conducted before 2010 (47%).

The researchers however note that population-based surveys of sexual behaviours depend on self-reports, so estimates could be under-reported as respondents provide more socially acceptable answers.

“Further prevention efforts are needed for this vulnerable population, including improved access to HIV testing and condom use initiatives,” conclude Dr Hodgins and colleagues. “Men who pay for sex should be recognised as a priority population for HIV prevention.”