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

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 middleincome 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%; I 2 = 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%; I 2 = 91.2%, p < 0.001), compared to studies whose data was collected between 2001-2010, i.e. 4%

Willingness to use HIV pre-Exposure Prophylaxis and its Factors among Female Sex Workers in Nekemte Town, Western Ethiopia

“…Age, education level, residence, and lack of HIV/AIDS knowledge were some factors associated with willingness to use PrEP reported in previous studies (15,21). In addition, stigma, fear of side effects, and poor user awareness were identi ed as possible factors of willingness to use PrEP (15,22,23); and fear of stigma, cost, and drug-drug interaction were also reported (12,18,24,25).…”

MPrEP+ study protocol: a prospective cohort study assessing the feasibility and acceptability of an HIV pre-exposure prophylaxis (PrEP) strategy for male clients of female sex workers in Kisumu, Kenya

“…This meta-analysis also estimated that only 67.5% of men surveyed between 2010 and 2020 reported using a condom during their last paid sex encounter. A second meta-analysis of 44 studies in low-income and middle-income countries conducted between 1989 and 2019 also found an elevated risk of HIV among men who purchased sex (5% pooled HIV prevalence; n=21 studies), and in studies conducted between 2011 and 2019 (2.85%), compared with men who did not purchase sex 1. Thus, an effective response to the elevated HIV vulnerability experienced by MC is essential to controlling the HIV epidemic, particularly in East and Southern Africa, where MC and other sexual partners of key populations, including FSW, accounted for 15% of new infections among those aged 15–49 years in 2019 4.…”

“…A second meta-analysis of 44 studies in low-income and middle-income countries conducted between 1989 and 2019 also found an elevated risk of HIV among men who purchased sex (5% pooled HIV prevalence; n=21 studies), and in studies conducted between 2011 and 2019 (2.85%), compared with men who did not purchase sex. 1 Thus, an effective response to the elevated HIV vulnerability experienced by MC is essential to controlling the HIV epidemic, particularly in East and Southern Africa, where MC and other sexual partners of key populations, including FSW, accounted for 15% of new infections among those aged 15–49 years in 2019. 4 However, data on factors associated with risk of HIV acquisition as well as studies of HIV prevention interventions among this population are limited, likely due to stigma, difficulty in identifying them and varying legality of commercial sex across countries.…”

“…Globally male clients (MCs) of female sex workers (FSWs) experience a greater burden of HIV compared with men who do not pay for sex1–3 due to a constellation of factors, including number of sexual partners, elevated HIV prevalence among FSW and patterns of condom use with FSWs. A recent meta-analysis of 87 population surveys in 35 sub-Saharan African countries between 2000 and 2020 indicated that paid sexual encounters by men are prevalent: 8% of sexually active men aged 15–54 reported they had ever paid for sex, and this per cent was higher in studies conducted in East Africa (11.3%) 3.…”

Understanding social and environmental factors and their contribution mechanisms to HIV transmission among heterosexual men in Indonesia

“…For example, high-risk behaviours, such as unprotected sex with multiple casual female partners or female sex workers (FSWs) and injecting drug use (IDU) practices, have been reported as proximal or direct factors that facilitate HIV transmission among men. [5][6][7][8][9][10] Poor general knowledge about HIV and condoms for prevention is another contributing factor for HIV transmission among men as it leads to men being unaware of the possibility of contracting HIV through such high-risk behaviours they engage in. [11][12][13] Men's negative attitudes towards condom use, past negative experiences of condom use practices in previous sexual encounters, 12,14,15 substance abuse and alcohol consumption prior to sex, [15][16][17] and intention to avoid sex partner's suspicion about their sexual relations with other women, 16,18 are all supporting reasons for men's engagement in unprotected sex.…”