Data on Transactional Sex Among MSM Highlight Need for Enhanced HIV Prevention

Men who have sex with men (MSM), in particular those paying for sex, need to be a priority population for targeted HIV prevention efforts in sub-Saharan Africa.

Twenty years of data from 87 population-based surveys that took place in sub-Saharan Africa (SSA) between 2000 and 2020 show men who paid to have sex (transactional sex) with another man are 50% more likely to acquire HIV. This, coupled with a lack of epidemiological research and HIV prevention efforts focused on male clients of sex workers, highlights the importance of targeted interventions among them.

Study finding were published online today in PLoS Medicine.

“Male clients of sex workers should be considered a key population that is at high risk of HIV and in need of increased prevention efforts,” according to a statement on the findings. “These data are striking and call for tailored HIV services for men paying for sex in this region.”

Data on more than 368,000 males (aged, 15-54 years) who ever reported paying for sex were collected and analyzed from Demographic and Health Surveys and AIDS Indicator Surveys (n = 78 surveys analyzed), Population-based HIV Impact Assessment (n = 6 surveys analyzed), the Kenya AIDS Indicator Survey (n = 1 survey analyzed), and the South Africa National HIV Prevalence, Incidence, Behaviour and Communication Survey (n = 2 surveys analyzed). The authors then conducted random-effects meta-analyses, extracting data on population size, lifetime number of sexual partners, condom use, HIV prevalence, HIV status, antiretroviral (ARV) use, and viral load suppression (VLS).

Among the study population, who represented 35 countries and 95% of the men in SSA, 8% (95% CI, 6%-10%) reported ever paying for sex. In addition to having the 50% (prevalence ratio [PR], 1.50; 95% CI, 1.31-1.72) greater risk of HIV, these men were also more likely to have ever tested for HIV (PR, 1.14; 95% CI, 1.06-1.24) vs men who did not engage in transactional sex.

Similar results were seen, however, when comparing lifetime levels of HIV testing, ARV use, and VLS between men living with HIV who did and did not pay for sex:

  • Ever tested for HIV: PR, 0.96 (95% CI, 0.88-1.05)
  • ARV use: PR, 1.01 (95% CI, 0.86-1.18)
  • VLS: PR, 1.00 (95% CI, 0.86-1.17)

Their study also found that despite disparities in reports of transactional sex between rural and urban dwellers and younger (aged 15-24 years) and older men (aged 35-54 years)—urban men are more likely to have engaged in transactional sex vs rural men (9.7% vs 7.1%) and younger men to pay for sex vs older men (5.1% vs 2.2%)—just 68% of the study cohort reported condom use during transactional sex, which researchers deemed, “suboptimal.”

Additional survey findings include the following:

  • The highest proportion of men who engaged in transactional sex were seen in Central (11.9%) and Eastern (11.3%) Africa
  • Average total of lifetime sexual partners was 12
  • Men living in Central Africa has the most lifetime sexual partners (19.6) and men in Eastern Africa, the fewest (10.2)
  • Men who engaged in transactional sex had an average 2.3 times more partners vs men who did not engage in transactional sex
  • Just 62.2% who reported transactional sex in the previous year used a condom during their last paid encounter
  • Men living in Southern African had the highest condom use (76.6%) and Eastern Africa, the lowest (55.2%)
  • Total condom use for the last paid encounter increased from 60.4% in 2010 to 75.7% in 2020
  • The pooled prevalence of ever having tested for HIV was 34.4%
  • Lifetime HIV testing increased from 31.9% in 2010 to 64.9% in 2020

The authors emphasized that it’s important to target men in SSA who engage in transactional sex for HIV prevention because of their reported sexual contact with not only sex workers, but other partners, which can increase rates of both acquisition and transmission of HIV.

However, they express that caution should be used when interpreting their data, due to its self-reported nature, the possibility of paying for sex outside of transactional sex (ie, exchanging gifts or favors for sex), and that different questionnaires and sampling strategies were used to gather the data analyzed.

“To more accurately determine population sizes of men who pay for sex, improved confidential methods should be employed,” the authors determined. “Condom use initiatives and improved access to HIV testing campaigns are required to prevent HIV transmission from clients to sex workers and to their other sexual partners.”


Hodgins C, Stannah J, Kuchukhidze S, et al. Population sizes, HIV prevalence, and HIV prevention among men who paid for sex in sub-Saharan Africa (2000–2020): a meta analysis of 87 population-based surveys. PLoS Med. Published online January 25, 2022. doi:10.1371/journal.pmed.1003861

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