Left behind?: male clients of female sex workers in Zambia.

ABSTRACT

Male clients of female sex workers (CFSWs) are a key-affected group within the HIV epidemic. However, few studies have quantified HIV/STI burdens among CFSWs. This study used nationally representative data from the 2013-14 Zambia Demographic and Health Survey to estimate proxies for HIV and STI prevalence among sexually active men aged 15-59 paying for sex recently (past 12 months) [5%, n = 679] or in their lifetime [15%, n = 1,887]. Chi-square tests were calculated to assess differences in prevalence estimates between CFSWs and non-clients. Multivariable logistic regression models were generated to identify sociodemographic factors associated with prevention characteristics. CFSWs had higher odds of reporting HIV infection (recent aOR 1.413, p < 0.05; lifetime aOR 1.604, p < 0.001) and past-year STI symptomology (recent aOR 3.342, p < 0.001; lifetime aOR 2.266, p < 0.001) than non-clients, irrespective of transactional sex recency. Compared to non-clients, CFSWs were more likely to be <25yo (42% vs. 29%, p < 0.001), have a cohabitating partner (43% vs. 35%, p < 0.001), use condoms at last sex (31% vs. 27%, p < 0.001), and never test for HIV (36% vs. 29%, p < 0.001). When comparing CFSWs to non-clients, marital status was an effect modifier of HIV testing, medical circumcision, and condom use at last sex. Findings suggest high HIV/STI burdens and highlight the urgent need for differentiated HIV prevention programming for CFSWs in Zambia including the provision of PrEP.