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Publications

Journal Article Review Epublish

PubMed: 42927180 DOI: 10.1016/j.eclinm.2026.104268

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.

EClinicalMedicine 101:104268

Authors: Joshua Dawe, Adam Trickey, Josephine Walker, Lucy Barrass, Belinda J Njiro, Bidisha Kundu, Matthew Hickman, Daniela Abramovitz, Malvina Aladashvili, Irina Artamonova, 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 Solomon, Steffanie A Strathdee, Vana Sypsa, Daniela Van Santen, Geng Zang, Jack Stone, Peter Vickerman, Adelina A Artenie

Affiliations

  • Bristol Population Health Science Institute, Bristol Medical School, Bristol, England, United Kingdom.
  • Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, USA.
  • AIDS and Clinical Immunology Research Center, Tbilisi, Georgia.
  • Institut National de Santé Publique du Québec, University of Montreal, Montreal, Canada.
  • Public Health Service of Amsterdam, Department of Infectious Diseases, Amsterdam, the Netherlands.
  • Department of Infectious Diseases, University of Bern, Bern, Switzerland.
  • Centre Hospitalier de l'Université de Montréal, CRCHUM, Montreal, Canada.
  • Département de Médecine de Famille et de Médecine d'urgence, Université de Montréal, Montreal, Canada.
  • School of Public Policy, Simon Fraser University, British Columbia, Canada.
  • New York University School of Global Public Health, New York University, New York, USA.
  • Disease Elimination, Burnet Institute, Melbourne, Australia.
  • Ukrainian Institute on Public Health Policy, Kyiv, Ukraine.
  • Department of Global and Public Health, McGill University, Montreal, Canada.
  • National and Kapodistrian University of Athens, Athens, Greece.
  • Department of Behavioral Science, University of Kentucky, Lexington, USA.
  • Public Health Institute, Liverpool John Moores University, Liverpool, England, United Kingdom.
  • United Kingdom Health Security Agency, London, England, United Kingdom.
  • Faculty of Health Sciences, Simon Fraser University, British Columbia, Canada.
  • New York Academy of Medicine, Yale University, CT, USA.
  • Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute, Sydney, Australia.
  • John Hopkins Bloomberg School of Public Health, John Hopkins University, Baltimore, USA.
  • School of Medicine, University of California San Francisco, San Francisco, USA.
  • Department of Internal Medicine, University of New Mexico, Albuquerque, USA.
  • Sexual Health and Blood Borne Viruses Research Group, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom.
  • Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, England, United Kingdom.
  • Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, United Kingdom.
  • Amsterdam Institute for Immunology and Infectious Diseases, Amsterdam, the Netherlands.
  • Department of Internal Medicine, University of Amsterdam, Amsterdam, the Netherlands.
  • Jawaharlal Nehru University, Delhi, India.
  • Population Council, Delhi, India.
  • School of Medicine, John Hopkins University, Baltimore, USA.
  • School of Medicine, University of California San Diego, San Diego, USA.
  • Health Protection Research Unit, Bristol Medical School, Bristol, England, United Kingdom.

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.

MeSH

Hepatitis C, Sexual Behavior, Incidence, Pharmaceutical Preparations, Sex Work, Work, Sex, Infections, Hepatitis