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The role of men who pay for sex in STI transmission: current knowledge and future directions. The contribution of the third UK National Survey of Sexual Attitudes and Lifestyles (Natsal-3)
  1. Sónia Dias
  1. Correspondence to Professor Sónia Dias, Institute of Hygiene and Tropical Medicine & CMDT, Universidade Nova de Lisboa, Rua da Junqueira, 100, Lisboa 1349-008, Portugal; sfdias{at}

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Sexually transmitted infections (STI) remain a major cause of morbidity and mortality worldwide. Worryingly, after nearly a decade of declining rates, STI incidence appears to be increasing in several regions.1 ,2

Men who pay for sex and their paid partners have been recognised as particularly vulnerable to STIs.1 Where data on STI prevalence in sex workers (SW) exist, outbreaks of STIs have been reported among this population.1 The few studies conducted with men who pay for sex indicate a high prevalence of STIs among this group.3 ,4 Most of this information comes from one-off surveys among convenience samples or attendances at STI clinics for screening, leading to uncertainty about how well these data truly reflect the STI burden in these populations.1

As currently discussed, men who pay for sex and their paid partners can act as a potential ‘bridge’ for STI transmission to lower-risk populations.2 ,5 Critical components of bridging include high rate of partner change, concurrency, patterns of sexual mixing with different types of partners (paid, non-paid, regular, casual, etc), inconsistent condom use and high rates of STI prevalence. Some of these characteristics have been documented in men who pay for sex, as illustrated in previous studies.3 ,5 ,6 A survey conducted in Benin with 404 clients recruited at sex work venues showed that many visit female SWs regularly, on a long-term basis, and visit a different SW each time. Furthermore, most clients had a regular partner or other casual non-female SW partners.6 Likewise, in a sexual health clinic survey in UK with 2665 men, 10% reported paid sex. The majority had paid for sex in the previous 12 months, and nearly a third on five or more occasions. Almost half the men paid for sex while in another relationship.3 In this light, it has been largely acknowledged that the spread of STIs among men who pay for sex is likely to be linked to their high rates of sexual partner change (commercial and non-commercial partners). Additionally, a number of studies report noteworthy findings showing a proportion of bisexual concurrency, with men having both female and male sexual partners,3 ,4 ,7 which may further increase the risk of STI transmission in high-risk sexual networks.

Another key aspect that has emerged as a risk factor is the mobility/migration. There is evidence of the rising proportion of men paying for sex with links to travel, sex tourism and high-risk sexual behaviours abroad.7 ,8 In the previously mentioned UK sexual health clinic survey, many men reported paying for sex abroad and, notably, they were almost twice as likely to engage in unprotected sex.3 Furthermore, there is a marked growth in the proportion of migrants involved in sex work.9 This is extremely important considering the recognised close link between migration and heightened risk of STI acquisition, but also the documented high prevalence rates of HIV among immigrant SWs from countries with generalised epidemics.1 ,9 Overall, it has been widely agreed that there is an increasing diversity of commercial sex, which entails different risk levels of STI infection.

Despite the potential role of those involved in commercial sex for the epidemic, data on SWs is relatively scarce and far less is known about men who pay for sex. In one review intended to estimate the prevalence of sexual contacts with SWs in several regions (few data from Europe and other high-income countries were available), it was estimated that between 1% and 14% of men had purchased sex from a female SW in the course of a year.5 As noted by Carael and colleagues,5 for many regions, the lack of surveys on commercial sex among the general population has been a major impediment for establishing national estimates of the size of key populations, as men who pay for sex. There is a clear need for a more in-depth understanding of the extent of the paid sex phenomenon and the patterns and trends in the key behaviours that influence STI/HIV transmission dynamics. Crucial information includes: characteristics of men paying for sex and paid partners (age, origin, travel habits); commercial sex patterns (prevalence across regions, mobility, sex work settings, same-sex contact, changes of contact with SWs over time); experience of sexual violence, particularly in a context of drug use; usage of STI clinic services, among others. This evidence would be valuable to inform about how these parameters influence the trajectory of the epidemic and support the HIV prevention programmes in effectively allocating resources and interventions to where they will have the greatest impact.

The third UK National Survey of Sexual Attitudes and Lifestyles (Natsal-3) offers a relevant contribution by providing insights into the extent, characteristics and role of men who pay for sex in STI transmission in the European context. The evidence found that men paying for sex report high number of partners, including foreign partners outside the UK, and are more likely to report STI diagnoses strongly supports that they are key populations to be targeted.

The other important accomplishment of Natsal-3 is using data from a population-based survey that are broadly representative of the general population, while most research has been based on small convenience sample data. Natsal-3 also presents strong methodological characteristics in terms of survey methods.7 ,10 The study used a combination of computer-assisted techniques that have been successfully used providing greater privacy for those surveyed, helping minimise memory and social desirability biases and eliciting more reliable reporting of stigmatised behaviours.5 Overall, this survey provides valuable data on the prevalence of men who pay for sex, presents estimates of STI diagnoses, updates the understanding of where British men pay for sex abroad and the factors associated with paying for sex. Indeed, the strategy of using data supplied by national health surveys of the general population to assess the prevalence and characteristics of men paying for sex could be replicated in other countries where studies on paid sex are absent. However, as a national survey focused on a wide range of sexual behaviours, Natsal-3 collected limited data about paying for sex.

Globally, there is an ongoing challenge of defining, reaching and studying hard-to-reach populations as men who pay for sex.1 ,5 Indeed, research on this group has been sparse, largely because they are poorly represented in national HIV surveillance systems. This calls for complementary research with alternative sampling/recruitment strategies for segments of population that are not efficiently ‘captured’ using conventional surveillance data collection methods. Encouraging the enhancement of research and effective knowledge translation will permit to more efficiently improve programme design and implementation, achieving higher coverage of men paying for sex. Undoubtedly, there have been missed opportunities for prevention activities in the community as in healthcare services directed towards those who probably have most effective control over adopting safer sex behaviours.

Natsal-3 illustrates a relevant effort to generate evidence of the role of men who pay for sex in STI transmission. Much more must be done to comprehensively understand this area of research and to intervene successfully in sexual health promotion of those directly and indirectly involved in commercial sex.


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  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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