{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T12:19:19Z","timestamp":1790857159451,"version":"4.1.0"},"reference-count":53,"publisher":"Public Library of Science (PLoS)","issue":"1","license":[{"start":{"date-parts":[[2022,1,25]],"date-time":"2022-01-25T00:00:00Z","timestamp":1643068800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001804","name":"Canada Research Chairs","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100001804","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000024","name":"Canadian Institutes of Health Research","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000024","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\"><jats:title>Background<\/jats:title><jats:p>Key populations, including sex workers, are at high risk of HIV acquisition and transmission. Men who pay for sex can contribute to HIV transmission through sexual relationships with both sex workers and their other partners. To characterize the population of men who pay for sex in sub-Saharan Africa (SSA), we analyzed population size, HIV prevalence, and use of HIV prevention and treatment.<\/jats:p><\/jats:sec><jats:sec id=\"sec002\"><jats:title>Methods and findings<\/jats:title><jats:p>We performed random-effects meta-analyses of population-based surveys conducted in SSA from 2000 to 2020 with information on paid sex by men. We extracted population size, lifetime number of sexual partners, condom use, HIV prevalence, HIV testing, antiretroviral (ARV) use, and viral load suppression (VLS) among sexually active men. We pooled by regions and time periods, and assessed time trends using meta-regressions. We included 87 surveys, totaling over 368,000 male respondents (15\u201354 years old), from 35 countries representing 95% of men in SSA. Eight percent (95% CI 6%\u201310%; number of surveys [<jats:italic>N<\/jats:italic><jats:sub>s<\/jats:sub>] = 87) of sexually active men reported ever paying for sex. Condom use at last paid sex increased over time and was 68% (95% CI 64%\u201371%;<jats:italic>N<\/jats:italic><jats:sub>s<\/jats:sub>= 61) in surveys conducted from 2010 onwards. Men who paid for sex had higher HIV prevalence (prevalence ratio [PR] = 1.50; 95% CI 1.31\u20131.72;<jats:italic>N<\/jats:italic><jats:sub>s<\/jats:sub>= 52) and were more likely to have ever tested for HIV (PR = 1.14; 95% CI 1.06\u20131.24;<jats:italic>N<\/jats:italic><jats:sub>s<\/jats:sub>= 81) than men who had not paid for sex. Men living with HIV who paid for sex had similar levels of lifetime HIV testing (PR = 0.96; 95% CI 0.88\u20131.05;<jats:italic>N<\/jats:italic><jats:sub>s<\/jats:sub>= 18), ARV use (PR = 1.01; 95% CI 0.86\u20131.18;<jats:italic>N<\/jats:italic><jats:sub>s<\/jats:sub>= 8), and VLS (PR = 1.00; 95% CI 0.86\u20131.17;<jats:italic>N<\/jats:italic><jats:sub>s<\/jats:sub>= 9) as those living with HIV who did not pay for sex. Study limitations include a reliance on self-report of sensitive behaviors and the small number of surveys with information on ARV use and VLS.<\/jats:p><\/jats:sec><jats:sec id=\"sec003\"><jats:title>Conclusions<\/jats:title><jats:p>Paying for sex is prevalent, and men who ever paid for sex were 50% more likely to be living with HIV compared to other men in these 35 countries. Further prevention efforts are needed for this vulnerable population, including improved access to HIV testing and condom use initiatives. Men who pay for sex should be recognized as a priority population for HIV prevention.<\/jats:p><\/jats:sec>","DOI":"10.1371\/journal.pmed.1003861","type":"journal-article","created":{"date-parts":[[2022,1,25]],"date-time":"2022-01-25T18:23:27Z","timestamp":1643135007000},"page":"e1003861","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":27,"title":["Population sizes, HIV prevalence, and HIV prevention among men who paid for sex in sub-Saharan Africa (2000\u20132020): A meta-analysis of 87 population-based surveys"],"prefix":"10.1371","volume":"19","author":[{"given":"Caroline","family":"Hodgins","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2652-872X","authenticated-orcid":true,"given":"James","family":"Stannah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Salome","family":"Kuchukhidze","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2239-4296","authenticated-orcid":true,"given":"Lycias","family":"Zembe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7728-728X","authenticated-orcid":true,"given":"Jeffrey W.","family":"Eaton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marie-Claude","family":"Boily","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8363-4388","authenticated-orcid":true,"given":"Mathieu","family":"Maheu-Giroux","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,1,25]]},"reference":[{"key":"pmed.1003861.ref001","volume-title":"UNAIDS data 2020.","author":"Joint United Nations Programme on HIV\/AIDS","year":"2020"},{"key":"pmed.1003861.ref002","volume-title":"Fast track: ending the AIDS epidemic by 2030","author":"Joint United Nations Programme on HIV\/AIDS","year":"2014"},{"key":"pmed.1003861.ref003","volume-title":"Consolidated guidelines on HIV prevention, diagnosis, treatment, and care for key populations.","author":"World Health Organization","year":"2016"},{"key":"pmed.1003861.ref004","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1097\/COH.0000000000000034","article-title":"Concentrated HIV subepidemics in generalized epidemic settings","volume":"9","author":"F Tanser","year":"2014","journal-title":"Curr Opin HIV AIDS"},{"key":"pmed.1003861.ref005","doi-asserted-by":"crossref","first-page":"538","DOI":"10.1016\/S1473-3099(12)70066-X","article-title":"Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis","volume":"12","author":"S Baral","year":"2012","journal-title":"Lancet Infect Dis"},{"key":"pmed.1003861.ref006","doi-asserted-by":"crossref","first-page":"e42","DOI":"10.2105\/AJPH.2014.301909","article-title":"A systematic review of the correlates of violence against sex workers.","volume":"104","author":"KN Deering","year":"2014","journal-title":"Am J Public Health"},{"key":"pmed.1003861.ref007","doi-asserted-by":"crossref","first-page":"S171","DOI":"10.1097\/QAI.0000000000000451","article-title":"Sexual violence, condom negotiation, and condom use in the context of sex work: results from two West African countries.","volume":"68","author":"AL Wirtz","year":"2015","journal-title":"J Acquir Immune Defic Syndr"},{"key":"pmed.1003861.ref008","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1038\/s41467-020-14593-6","article-title":"The role of sex work laws and stigmas in increasing HIV risks among sex workers.","volume":"11","author":"CE Lyons","year":"2020","journal-title":"Nat Commun."},{"key":"pmed.1003861.ref009","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1097\/QAI.0000000000001434","article-title":"Changing dynamics of HIV transmission in C\u00f4te d\u2019Ivoire: modeling who acquired and transmitted infections and estimating the impact of past HIV interventions (1976\u20132015).","volume":"75","author":"M Maheu-Giroux","year":"2017","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"Suppl 2","key":"pmed.1003861.ref010","doi-asserted-by":"crossref","first-page":"S180","DOI":"10.1097\/QAI.0000000000000441","article-title":"Potential impact of existing interventions and of antiretroviral use in female sex workers on transmission of HIV in Burkina Faso: a modeling study.","volume":"68","author":"A Low","year":"2015","journal-title":"J Acquir Immune Defic Syndr"},{"key":"pmed.1003861.ref011","doi-asserted-by":"crossref","first-page":"e25126","DOI":"10.1002\/jia2.25126","article-title":"Estimating the contribution of key populations towards the spread of HIV in Dakar","volume":"21","author":"C Mukandavire","year":"2018","journal-title":"Senegal. J Int AIDS Soc"},{"key":"pmed.1003861.ref012","doi-asserted-by":"crossref","first-page":"945","DOI":"10.1097\/00002030-200404090-00013","article-title":"The central role of clients of female sex workers in the dynamics of heterosexual HIV transmission in sub-Saharan Africa","volume":"18","author":"M Alary","year":"2005","journal-title":"AIDS"},{"key":"pmed.1003861.ref013","doi-asserted-by":"crossref","first-page":"e63476","DOI":"10.1371\/journal.pone.0063476","article-title":"HIV due to female sex work: regional and global estimates.","volume":"8","author":"A Pr\u00fcss-Ust\u00fcn","year":"2013","journal-title":"PLoS ONE"},{"issue":"Suppl 2","key":"pmed.1003861.ref014","doi-asserted-by":"crossref","first-page":"S74","DOI":"10.1097\/QAI.0000000000000437","article-title":"What really is a concentrated HIV epidemic and what does it mean for West and Central Africa? Insights from mathematical modeling.","volume":"68","author":"M-C Boily","year":"2015","journal-title":"J Acquir Immune Defic Syndr"},{"key":"pmed.1003861.ref015","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1136\/sti.2004.011940","article-title":"Male clients of brothel prostitutes as a bridge for HIV infection between high risk and low risk groups of women in Senegal.","volume":"81","author":"ME Gomes do Espirito Santo","year":"2005","journal-title":"Sex Transm Infect"},{"issue":"Suppl 3","key":"pmed.1003861.ref016","first-page":"iii26","article-title":"Clients of sex workers in different regions of the world: hard to count.","volume":"82","author":"M Carael","year":"2006","journal-title":"Sex Transm Infect"},{"key":"pmed.1003861.ref017","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1097\/00007435-200208000-00003","article-title":"Clients of female sex workers in Nyanza Province, Kenya: a core group in STD\/HIV transmission.","volume":"29","author":"HACM Voeten","year":"2002","journal-title":"Sex Transm Dis"},{"key":"pmed.1003861.ref018","doi-asserted-by":"crossref","first-page":"2523","DOI":"10.1097\/00002030-200011100-00015","article-title":"Management of sexually transmitted diseases and HIV prevention in men at high risk: targeting clients and non-paying sexual partners of female sex workers in Benin","volume":"14","author":"CM Lowndes","year":"2000","journal-title":"AIDS"},{"key":"pmed.1003861.ref019","doi-asserted-by":"crossref","first-page":"1691","DOI":"10.1097\/00002030-200307250-00014","article-title":"HIV prevalence and risk behavior among clients of female sex workers in Abidjan, C\u00f4te d\u2019Ivoire","volume":"17","author":"BL Vuylsteke","year":"2003","journal-title":"AIDS"},{"key":"pmed.1003861.ref020","doi-asserted-by":"crossref","first-page":"537","DOI":"10.2471\/BLT.05.029520","article-title":"HIV testing in national population-based surveys: experience from the Demographic and Health Surveys","volume":"84","author":"V Mishra","year":"2006","journal-title":"Bull World Health Organ"},{"key":"pmed.1003861.ref021","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1177\/0956462415581728","article-title":"The utility of population-based surveys to describe the continuum of HIV services for key and general populations","volume":"27","author":"W Hladik","year":"2016","journal-title":"Int J STD AIDS"},{"key":"pmed.1003861.ref022","doi-asserted-by":"crossref","first-page":"595","DOI":"10.1136\/sextrans-2012-050884","article-title":"Assessment of HIV-related risky behaviour: a comparative study of face-to-face interviews and polling booth surveys in the general population of Cotonou, Benin.","volume":"89","author":"L B\u00e9hanzin","year":"2013","journal-title":"Sex Transm Infect."},{"key":"pmed.1003861.ref023","doi-asserted-by":"crossref","first-page":"1539","DOI":"10.1002\/sim.1186","article-title":"Quantifying heterogeneity in a meta-analysis.","volume":"21","author":"JPT Higgins","year":"2002","journal-title":"Stat Med"},{"key":"pmed.1003861.ref024","doi-asserted-by":"crossref","first-page":"103","DOI":"10.12688\/wellcomeopenres.15311.1","article-title":"rdhs: an R package to interact with The Demographic and Health Surveys (DHS) Program datasets [version 1; peer review: 1 approved, 1 approved with reservations].","volume":"4","author":"O Watson","year":"2019","journal-title":"Wellcome Open Res"},{"key":"pmed.1003861.ref025","article-title":"survey: analysis of complex survey samples","author":"T. Lumley","year":"2020","journal-title":"R package version 4.0. Comprehensive R Archive Network"},{"issue":"3","key":"pmed.1003861.ref026","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v036.i03","article-title":"Conducting meta-analyses in R with the metafor package.","volume":"36","author":"W. Viechtbauer","year":"2010","journal-title":"J Stat Softw"},{"key":"pmed.1003861.ref027","doi-asserted-by":"crossref","first-page":"2008","DOI":"10.1001\/jama.283.15.2008","article-title":"Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group","volume":"283","author":"DF Stroup","year":"2000","journal-title":"JAMA"},{"key":"pmed.1003861.ref028","author":"Population Division","year":"2019"},{"key":"pmed.1003861.ref029","volume-title":"Assessing the impact of imperfect Immunoassays on HIV prevalence estimates from surveys conducted by the DHS Program","author":"M Maheu-Giroux","year":"2017"},{"key":"pmed.1003861.ref030","doi-asserted-by":"crossref","first-page":"100459","DOI":"10.1016\/j.ssmph.2019.100459","article-title":"Paid sex among men in sub-Saharan Africa: analysis of the demographic and health survey.","volume":"11","author":"A-A Seidu","year":"2020","journal-title":"SSM Popul Health"},{"issue":"Suppl 3","key":"pmed.1003861.ref031","first-page":"iii18","article-title":"Estimates of the number of female sex workers in different regions of the world.","volume":"82","author":"J Vandepitte","year":"2006","journal-title":"Sex Transm Infect"},{"key":"pmed.1003861.ref032","volume-title":"Estimating the size of populations through a household survey (ESPHS): Rwanda 2011.","author":"Rwanda Biomedical Center\/Institute of HIV\/AIDS Disease Prevention and Control Department","year":"2012"},{"key":"pmed.1003861.ref033","doi-asserted-by":"crossref","first-page":"660","DOI":"10.1258\/ijsa.2008.008099","article-title":"Commercial sex and HIV transmission in mature epidemics: a study of five African countries","volume":"19","author":"PM Leclerc","year":"2008","journal-title":"Int J STD AIDS"},{"key":"pmed.1003861.ref034","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1097\/QAI.0000000000001956","article-title":"Cost-effectiveness of accelerated HIV response scenarios in C\u00f4te d\u2019Ivoire.","volume":"80","author":"M Maheu-Giroux","year":"2019","journal-title":"J Acquir Immune Defic Syndr"},{"key":"pmed.1003861.ref035","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1080\/09540120512331325635","article-title":"Factors associated with self-reported HIV testing among men in Uganda.","volume":"17","author":"AJ Gage","year":"2005","journal-title":"AIDS Care"},{"key":"pmed.1003861.ref036","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1186\/s12889-018-6362-0","article-title":"Determinants of access to HIV testing and counselling services among female sex workers in sub-Saharan Africa: a systematic review.","volume":"19","author":"S Nnko","year":"2019","journal-title":"BMC Public Health"},{"key":"pmed.1003861.ref037","doi-asserted-by":"crossref","first-page":"e284","DOI":"10.1016\/S2352-3018(20)30315-5","article-title":"Trends in knowledge of HIV status and efficiency of HIV testing services in sub-Saharan Africa, 2000\u201320: a modelling study using survey and HIV testing programme data","volume":"8","author":"K Gigu\u00e8re","year":"2021","journal-title":"Lancet HIV"},{"key":"pmed.1003861.ref038","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1186\/s12889-021-10212-1","article-title":"Describing, analysing and understanding the effects of the introduction of HIV self-testing in West Africa through the ATLAS programme in C\u00f4te d\u2019Ivoire, Mali and Senegal.","volume":"21","author":"N Rouveau","year":"2021","journal-title":"BMC Public Health"},{"key":"pmed.1003861.ref039","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1097\/QAI.0000000000002580","article-title":"Quantifying the evolving contribution of HIV interventions and key populations to the HIV epidemic in Yaound\u00e9, Cameroon.","volume":"86","author":"R Silhol","year":"2021","journal-title":"J Acquir Immune Defic Syndr"},{"key":"pmed.1003861.ref040","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1186\/s12889-018-5208-0","article-title":"Progress towards the UNAIDS 90-90-90 goals by age and gender in a rural area of KwaZulu-Natal, South Africa: a household-based community cross-sectional survey.","volume":"18","author":"H Huerga","year":"2018","journal-title":"BMC Public Health"},{"key":"pmed.1003861.ref041","doi-asserted-by":"crossref","first-page":"e000125","DOI":"10.1136\/bmjgh-2016-000125","article-title":"Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review","volume":"1","author":"T Heestermans","year":"2016","journal-title":"BMJ Glob Health"},{"key":"pmed.1003861.ref042","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/S0140-6736(14)61049-7","article-title":"Lives on the line: sex work in sub-Saharan Africa","volume":"385","author":"A. Baleta","year":"2015","journal-title":"Lancet"},{"issue":"8","key":"pmed.1003861.ref043","doi-asserted-by":"crossref","first-page":"e0236552","DOI":"10.1371\/journal.pone.0236552","article-title":"Consistent condom use among men who pay for sex in sub-Saharan Africa: empirical evidence from Demographic and Health Surveys.","volume":"15","author":"BO Ahinkorah","year":"2020","journal-title":"PLoS ONE"},{"key":"pmed.1003861.ref044","doi-asserted-by":"crossref","first-page":"e1002321","DOI":"10.1371\/journal.pmed.1002321","article-title":"Population-level impact of an accelerated HIV response plan to reach the UNAIDS 90-90-90 target in C\u00f4te d\u2019Ivoire: insights from mathematical modeling.","volume":"14","author":"M Maheu-Giroux","year":"2017","journal-title":"PLoS Med"},{"key":"pmed.1003861.ref045","doi-asserted-by":"crossref","first-page":"S4","DOI":"10.1186\/1471-2458-11-S6-S4","article-title":"Prevalence of HIV and sexually transmitted infections among clients of female sex workers in Karnataka, India: a cross-sectional study.","volume":"11","author":"SY Shaw","year":"2011","journal-title":"BMC Public Health"},{"key":"pmed.1003861.ref046","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1111\/j.1365-3156.2009.02464.x","article-title":"How to improve the validity of sexual behaviour reporting: systematic review of questionnaire delivery modes in developing countries","volume":"15","author":"LF Langhaug","year":"2010","journal-title":"Trop Med Int Health"},{"key":"pmed.1003861.ref047","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1363\/3901413","article-title":"Social desirability bias in sexual behavior reporting: evidence from an interview mode experiment in rural Malawi.","volume":"39","author":"CA Kelly","year":"2013","journal-title":"Int Perspect Sex Reprod Health"},{"key":"pmed.1003861.ref048","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1023\/A:1018682530519","article-title":"Reliability and validity of self-report measures of HIV-related sexual behaviour: progress since 1990 and recommendations for research and practice.","volume":"27","author":"LS Weinhardt","year":"1998","journal-title":"Arch Sex Behav."},{"key":"pmed.1003861.ref049","doi-asserted-by":"crossref","first-page":"1541","DOI":"10.1093\/ije\/dyq114","article-title":"A systematic review and meta-analysis of quantitative interviewing tools to investigate self-reported HIV and STI associated behaviours in low- and middle-income countries.","volume":"39","author":"AE Phillips","year":"2010","journal-title":"Int J Epidemiol"},{"key":"pmed.1003861.ref050","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1186\/1471-2288-13-11","article-title":"Evaluating audio computer assisted self-interviews in urban south African communities: evidence for good suitability and reduced social desirability bias of a cross-sectional survey on sexual behaviour","volume":"13","author":"R Beauclair","year":"2013","journal-title":"BMC Med Res Methodol"},{"key":"pmed.1003861.ref051","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1002\/casp.2361","article-title":"Sugar daddies and blessers: a contextual study of transactional sexual interactions among young girls and older men.","volume":"28","author":"J Hoss","year":"2018","journal-title":"J Community Appl Soc Psychol"},{"key":"pmed.1003861.ref052","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1186\/1471-2458-12-325","article-title":"Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South Africa men.","volume":"12","author":"R Jewkes","year":"2012","journal-title":"BMC Public Health"},{"key":"pmed.1003861.ref053","volume-title":"Recommended population size estimates of men who have sex with men.","author":"Joint United Nations Programme on HIV\/AIDS","year":"2020"}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003861","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,16]],"date-time":"2023-11-16T07:54:54Z","timestamp":1700121294000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003861"}},"subtitle":[],"editor":[{"given":"Marie-Louise","family":"Newell","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2022,1,25]]},"references-count":53,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,1,25]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pmed.1003861","relation":{},"ISSN":["1549-1676"],"issn-type":[{"value":"1549-1676","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,1,25]]}}}