Sex work or male-with-male sexual activity and the risks of HIV and hepatitis C acquisition among people who inject drugs: a global systematic review and meta-analysis
Abstract
Background People who inject drugs (PWID) may engage in sexual behaviours that increase their HIV and hepatitis C virus (HCV) risk, including sex work and male-with-male sexual activity. We undertook a global systematic review to assess whether PWID who engage in these behaviours have higher HIV and HCV acquisition risks. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO for studies among PWID published between 01/01/2000 and 09/06/2026 that included estimates of the association between male-with-male sex or sex work and our primary outcomes of HIV or HCV incidence. Studies that estimated incidence by longitudinally re-testing people at risk of infection or by using assays for recent infection were eligible for inclusion. We also contacted authors for unpublished estimates. We pooled estimates using random-effects meta-analysis. We used I 2 to assess heterogeneity, and we used Egger's test to assess publication asymmetry. This review is registered with Prospero (CRD42020220884). Findings We included 57 studies comprising 164 estimates. Among men, recent male-with-male sex was associated with higher HIV acquisition (pooled incidence rate ratio (IRR):2.35; 95% CI: 1.51–3.66; I 2 : 51%).) but not HCV (IRR: 1.28; 95% CI: 0.95–1.72; I 2 : 21%). Recent sex work had a 1.72-fold (95% CI: 1.30–2.28; I 2 : 65%) and 1.59-fold (95% CI: 1.29–1.96; I 2 : 60%) higher HIV and HCV acquisition risk among all PWID, respectively. When stratified, sex work was associated with higher HIV acquisition among women (IRR: 2.30; 95% CI: 1.44–3.68; I 2 : 68%) but not men (IRR: 1.43; 95% CI: 0.92–2.22; I 2 : 51%), and was associated with HCV acquisition among men (IRR: 1.51; 95% CI: 1.22–1.87; I 2 : 0%), but not women (IRR: 1.26; 95% CI: 0.90–1.77; I 2 : 55%). For lifetime behaviours, only male-with-male sex was associated with HIV acquisition (IRR: 2.44; 95% CI: 1.18–5.02; I 2 = 87%). Results from Egger's tests did not provide evidence of asymmetry bias for our pooled estimates, while I 2 measures suggested considerable heterogeneity for many outcomes. Interpretation PWID who also engage in sex work or male-with-male sex were found to have higher HIV or HCV acquisition risks. Future research should aim to understand the mechanisms driving these associations. Funding Medical Research Council Greater Western Four Partnership Doctoral Training Partnership, Wellcome Trust, Canadian Institutes of Health Research and Medical Research Council.
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Authors: Josh Dawe, Adam Trickey, Josephine G. Walker, Lucy Barrass, Belinda Njiro, Bidisha Kundu, Matt Hickman, Daniela Abramovitz, Malvina Aladashvili, Irina Artamónova, Karine Blouin, Anders Boyd, Julie Bruneau, Kora DeBeck, Don Des Jarlais, Paul Dietze, Kostyantyn Dumchev, Catherine Hankins, Angelos Hatzakis, Jennifer R. Havens, Vivian Hope, Kanna Hayashi, Vita Jongen, Ann Kurth, Lisa Maher, Shruti Mehta, Holly Mitchell, Meghan D. Morris, Kimberly Page, Norah E. Palmateer, Lucy Platt, Maria Prins, Kasun Rathnayake, Lopamudra Ray Saraswati, Sotirios Roussos, Rachel Sacks‐Davis, Avina Sarna, Sunil Suhas Solomon, Steffanie Anne Strathdee, Vana Sypsa, Daniela K van Santen, Geng Zang, Jack Stone, Peter T. Vickerman, Adelina Artenie
Institutions: University of California San Diego, Johns Hopkins University, Université de Montréal, London School of Hygiene & Tropical Medicine, University of California, San Francisco, University of Amsterdam, New York University, University of Bern, University of Kentucky, McGill University, Liverpool John Moores University, Centre Hospitalier de l’Université de Montréal, National and Kapodistrian University of Athens, Simon Fraser University, University of New Mexico, At Bristol, Glasgow Caledonian University, Jawaharlal Nehru University, Burnet Institute, Institut National de Santé Publique, National Security Agency, GGD Amsterdam, Population Council, Institut National de Santé Publique du Québec, Royal Society of Tropical Medicine and Hygiene, Amsterdam institute for Immunology and Infectious Diseases, AIDS and Clinical Immunology Research Center, Ukrainian Institute of Public Health Policy, New York Academy of Sciences