HIV programmes and research have traditionally focused on female sex workers and less often on their male customers. This is partially redressed by a meta-analysis showing that 5% of men who purchase sex in low- and middle-income countries have HIV, a rate which is roughly double that of other men living in the same communities.
“These findings are further evidence that men who purchase sex should be designated as a key population in many countries, and that interventions to reduce HIV risk among these men should be prioritized,” write Dr Luh Putu Lila WulandariI of the University of New South Wales and colleagues in PLOS ONE.
In 2012, a systematic review and meta-analysis showed that female sex workers had 14 times higher HIV prevalence than women of a similar age in the general population. Last year, another review showed that laws criminalising sex work are associated with a sevenfold increase in the odds of HIV infection among female sex workers in sub-Saharan Africa.
However, the HIV prevalence in male customers across low- and middle-income countries had not been calculated until now. The investigators conducted a systematic review to identify studies which reported on the prevalence of HIV in men who purchased sex from women, as well as studies which reported on HIV prevalence among both customers and non-customers in the same study, or provided information which allowed calculation of the prevalence. The results were pooled in a meta-analysis.
They identified 44 relevant studies: 24 studies from six Asian countries, 15 studies from 12 African countries, four studies from four Latin American countries, and one study from the Russian Federation. The studies recruited men from locations used for sex work (41%), STI clinics (30%) and work places such as military camps and truck stops (23%).
Just under 60,000 men were included in the 44 studies, of whom 80% were men who purchased sex.
The average prevalence of HIV among men who purchased sex was 5%, with only small variations by global region. Prevalence was higher in studies conducted before 2001 at 10%, decreasing to 4% between 2001 and 2010, and 3% in more recent studies. This may reflect decreases in new HIV infections seen in recent years.
There was a high degree of heterogeneity – in other words large variations in the results from study to study.
Across the studies, HIV prevalence among men who purchase sex was higher than the male adult prevalence in the same country. The overall risk of HIV among male customers was almost twice as high as it was in non-customers within the same populations (relative risk 1.95, 95% confidence interval 1.56-2.44), with the difference being larger in the more recent studies (relative risk 2.85, 95% confidence interval 1.04-7.76).
Wulandaril and colleagues note that in addition to potential exposure to HIV through transactional sex, previous studies have shown that this group of men are more likely to have multiple partners (including male partners), to have sex under the influence of drugs, to have a history of injecting drug use and to have high rates of STIs.
Wulandari LPL et al. The burden of HIV infection among men who purchase sex in low- and middle-income countries – a systematic review and meta-analysis. PLOS ONE, 15: e0238639, 4 September 2020 (open access).