Men who pay for sex: a missing at-risk population?

National surveys collected over 20 years in 35 African countries provides strong evidence that men who pay for sex should be classified as an ‘at-risk’ population for HIV.

What is the research about?

Men in sub-Saharan Africa who pay for sex and how this relates to HIV.

The study analysed 87 nationally-representative surveys that contained questions on paying for sex (it did not look at other types of transactional sex). Around 368,000 men participated in the surveys, which were conducted between 2000 to 2020.

Why is this research important?

Men who pay for sex can contribute to HIV transmission by having sex with sex workers and other partners. But they are not officially recognised as a ‘key population’ (a population group that is highly vulnerable to HIV).

What did they find out?

Around one in ten (8%) sexually active men reported paying for sex at some point in their life. This was higher in urban areas (10%) than rural areas (7%) and remained stable over the 20 years.

In the past 12 months, 3% of men had paid for sex. Younger men (ages 15–24) were more than twice as likely to have paid for sex in the past 12 months than men aged 35–54 (5% compared to 2%).

Men who paid for sex were 50% more likely to have HIV than other men. HIV prevalence among men who had paid for sex was 5%, although this varied across regions.

Condom use has increased over time but is still low. In surveys from 2010 onwards, two-thirds (68%) of men used a condom the last time they paid for sex. Between 2000-10, fewer than half did (47%).

Men who paid for sex were more likely to test for HIV than other men. Lifetime HIV testing among men who paid for sex increased over time, from 32% in 2010 to 65% in 2020.

Men with HIV who paid for sex had similar levels of HIV testing, treatment use and viral load suppression as men with HIV who did not pay for sex (although data on treatment and viral load was limited).

The surveys used face-to-face questionnaires. So the number of men who paid for sex might be underreported due to the sensitive nature of the issue.

What does this mean for HIV services?

Men who pay for sex should be recognised as a priority population for HIV services.

It can be difficult to reach men who pay for sex because buying sex is often criminalised and stigmatised.

Understanding which men are paying for sex is an important first step. For example, studies suggest men who are migrant laborers, long-distance truck drivers, mine workers or who travel for work for other reasons are likely to pay for sex. Making non-judgemental HIV testing and treatment services available for these groups in places where they live, socialise and work could be effective. The finding that younger men are more likely to pay for sex than older men should also be considered.

Providing HIV self-testing kits to sex workers to pass on to their clients, or directly to men, could be an effective strategy. This is likely to work better than index testing (which requires sex workers with HIV to disclose the identity of their clients), as this can put sex workers at risk of violence or income loss, or both.

Educating men who pay for sex about the risks they are taking and how to reduce these risks by using condoms is also important. Providing free condoms and lubricant could encourage use.