The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.
Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia.
PLoS One. 2020 Sep 4;15(9):e0238639. doi: 10.1371/journal.pone.0238639. eCollection 2020.
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 middle-income countries (LMICs), and the association between HIV infection and purchase of sex.
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.
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%; I2 = 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%; I2 = 91.2%, p < 0.001), compared to studies whose data was collected between 2001-2010, i.e. 4% (95%CI: 2%-6%; I2 = 96.6%, p < 0.001), and from 2011 and beyond, i.e. 3% (95% CI: 2%-5%; I2 = 94.3%, p < 0.001). For studies which included comparisons of HIV infection among MWPS and non-MWPS, the relative risk of HIV infection was consistently higher among MWPS than among non-MWPS within the same study, with the overall pooled relative risk of 1.95 (95%CI: 1.56-2.44; I2 = 84.3%, p < 0.001), and 2.85 (95%CI: 1.04-7.76; I2 = 86.5%, p < 0.001) for more recent studies.
This review represents the first comprehensive assessment of the burden of HIV among MWPS in LMICs. We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association between purchasing sex and HIV prevalence. Despite a reduction over time in prevalence, these data highlight that MWPS need better access to HIV preventive interventions.
自艾滋病疫情开始以来，交易性性关系被认为是艾滋病毒向客户和提供性服务的人传播的高风险。然而，预防研究和方案主要侧重于性工作者，而不是他们的客户，这些客户通常是男性。为了支持有效和有针对性的干预措施，我们对来自中低收入国家（LMIC）的男性购买性服务者（MWPS）中艾滋病毒感染的流行率以及艾滋病毒感染与购买性服务之间的关联进行了系统评价和荟萃分析。
我们纳入了在 LMIC 中报告了 MWPS 中艾滋病毒流行率的文章，以及在同一研究中报告了 MWPS 和非 MWPS 中艾滋病毒流行率的文章，或任何允许计算流行率的信息。我们将 MWPS 定义为主要从女性（而不是男性）购买性服务或与性工作者（FSWs）发生性接触的异性恋男性（不是购买性服务或其他性取向的男性）。我们在 Medline、全球健康、Scopus、Embase 和 Cinahl 中搜索了截至 2020 年 3 月 1 日发表的文章。使用随机效应模型进行荟萃分析，以估计合并的艾滋病毒流行率和与购买性服务相关的艾滋病毒感染的相对风险（RR）。
在筛选出的 34862 项研究中，我们纳入了来自 21 个国家的 44 项研究（59515 名男性，47753 名 MWPS）。MWPS 中的艾滋病毒流行率为 5%（95%CI：4%-6%；I2=95.9%，p<0.001）。从报告 2001 年前收集的数据的研究中计算出的艾滋病毒流行率最高，即 10%（95%CI：6%-14%；I2=91.2%，p<0.001），而 2001-2010 年期间收集的数据为 4%（95%CI：2%-6%；I2=96.6%，p<0.001），2011 年及以后的数据为 3%（95%CI：2%-5%；I2=94.3%，p<0.001）。对于包括比较 MWPS 和非 MWPS 中艾滋病毒感染的研究，MWPS 中艾滋病毒感染的相对风险始终高于同一研究中的非 MWPS，总体合并相对风险为 1.95（95%CI：1.56-2.44；I2=84.3%，p<0.001），最近的研究为 2.85（95%CI：1.04-7.76；I2=86.5%，p<0.001）。
本综述代表了对中低收入国家 MWPS 中艾滋病毒负担的首次全面评估。我们发现，与整个人口相比，艾滋病毒流行率较高，而且购买性服务与艾滋病毒流行率之间存在很强的关联。尽管流行率随时间有所下降，但这些数据突出表明，MWPS 需要更好地获得艾滋病毒预防干预措施。
