Should men who buy sex be considered a key population?
The first evidence review to focus on men who buy sex – rather than women who sell it – finds a strong association between purchasing sex and HIV.
The first comprehensive evidence review of its kind has found men who buy sex are twice as likely to get HIV than other men. It has also found HIV prevalence is consistently higher among men who buy sex than men in the general population.
The study analysed 44 studies published between 1989 and 2019 involving heterosexual men who buy sex from women. The studies were conducted in 21 low- and middle-income countries in sub-Saharan Africa, Latin America, Asia and Europe.
A total of 59,515 men were included in the studies, 80% of whom had bought sex. Most studies were based on self-reporting and defined buying sex as ever having bought sex, although a third of this group bought sex more recently - in the last three months.
Between 1% and 17% of men who buy sex were living with HIV in the studies analysed. This rate was always higher than the HIV prevalence among the general male population.
When taken as an overall ‘pooled’ measurement, 5% of men who buy sex were living with HIV. HIV prevalence was highest among men who buy sex in studies conducted before 2001, at 10%. Between 2001 and 2010, 4% of men who buy sex were living with HIV, a prevalence rate that fell to 3% after 2011.
When analysed by region, HIV prevalence among men who buy sex was highest in Africa at 6%, followed by Asia at 5%, and Latin America at 4%.
The study found the overall risk of acquiring HIV was almost twice as high (1.95) for men who buy sex than men who do not; a level that was similar across all regions. By 2011, this risk had risen to almost three times as high (2.85).
Despite a reduction in HIV prevalence over time, these findings show that men who buy sex have a higher risk of acquiring HIV than other men. In addition to the increased risk of HIV associated with buying sex, other studies have found men who buy sex are more likely than other men to have multiple sexual partners, are more likely to have other sexually transmitted infections, and are more likely to inject drugs – factors that all increase HIV vulnerability.
Taken collectively, the evidence indicates that more effective HIV prevention, testing and treatment services are needed for men who buy sex. That men who buy sex often have the final say on condom use, both with sex workers and other sexual partners gives further urgency to this.
To address this issue, the second part of this systematic review focusing on ways to prevent men who buy sex from acquiring HIV has been published.
The question even remains as to whether men who buy sex should be considered a ‘key population’ in HIV programming, on a level footing with people who sell the sex they buy.