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 We also contacted authors for unpublished estimates.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 I² 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; I²: 51%).) but not HCV (IRR: 1.28; 95% CI: 0.95-1.72; I²: 21%). Recent sex work had a 1.72-fold (95% CI: 1.30-2.28; I²: 65%) and 1.59-fold (95% CI: 1.29-1.96; I²: 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; I²: 68%) but not men (IRR: 1.43; 95% CI: 0.92-2.22; I²: 51%), and was associated with HCV acquisition among men (IRR: 1.51; 95% CI: 1.22-1.87; I²: 0%), but not women (IRR: 1.26; 95% CI: 0.90-1.77; I²: 55%). For lifetime behaviours, only male-with-male sex was associated with HIV acquisition (IRR: 2.44; 95% CI: 1.18-5.02; I² = 87%). Results from Egger's tests did not provide evidence of asymmetry bias for our pooled estimates, while I² 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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BibTeX
@article{dawe2026work,
title = {{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}},
author = {Joshua Dawe and Adam Trickey and Josephine Walker and Lucy Barrass and Belinda J. Njiro and Bidisha Kundu and Matthew Hickman and Daniela Abramovitz and Malvina Aladashvili and Irina Artamonova and Karine Blouin and Anders Boyd and Julie Bruneau and Kora DeBeck and Don Des Jarlais and Paul Dietze and Kostyantyn Dumchev and Catherine Hankins and Angelos Hatzakis and Jennifer R. Havens and Vivian Hope and Kanna Hayashi and Vita Jongen and Ann Kurth and Lisa Maher and Shruti Mehta and Holly Mitchell and Meghan D. Morris and Kimberly Page and Norah E. Palmateer and Lucy Platt and Maria Prins and Kasun Rathnayake and Lopamudra Ray Saraswati and Sotirios Roussos and Rachel Sacks-Davis and Avina Sarna and Sunil Solomon and Steffanie A. Strathdee and Vana Sypsa and Daniela Van Santen and Geng Zang and Jack Stone and Peter Vickerman and Adelina A. Artenie},
journal = {eClinicalMedicine},
year = {2026},
month = oct,
doi = {10.1016/j.eclinm.2026.104268},
url = {https://linkinghub.elsevier.com/retrieve/pii/S2589537026005213},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - 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
AU - Joshua Dawe
AU - Adam Trickey
AU - Josephine Walker
AU - Lucy Barrass
AU - Belinda J. Njiro
AU - Bidisha Kundu
AU - Matthew Hickman
AU - Daniela Abramovitz
AU - Malvina Aladashvili
AU - Irina Artamonova
AU - Karine Blouin
AU - Anders Boyd
AU - Julie Bruneau
AU - Kora DeBeck
AU - Don Des Jarlais
AU - Paul Dietze
AU - Kostyantyn Dumchev
AU - Catherine Hankins
AU - Angelos Hatzakis
AU - Jennifer R. Havens
AU - Vivian Hope
AU - Kanna Hayashi
AU - Vita Jongen
AU - Ann Kurth
AU - Lisa Maher
AU - Shruti Mehta
AU - Holly Mitchell
AU - Meghan D. Morris
AU - Kimberly Page
AU - Norah E. Palmateer
AU - Lucy Platt
AU - Maria Prins
AU - Kasun Rathnayake
AU - Lopamudra Ray Saraswati
AU - Sotirios Roussos
AU - Rachel Sacks-Davis
AU - Avina Sarna
AU - Sunil Solomon
AU - Steffanie A. Strathdee
AU - Vana Sypsa
AU - Daniela Van Santen
AU - Geng Zang
AU - Jack Stone
AU - Peter Vickerman
AU - Adelina A. Artenie
PY - 2026
DA - 2026/10/14
JO - eClinicalMedicine
DO - 10.1016/j.eclinm.2026.104268
UR - https://linkinghub.elsevier.com/retrieve/pii/S2589537026005213
AB - 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 I² 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; I²: 51%).) but not HCV (IRR: 1.28; 95% CI: 0.95-1.72; I²: 21%). Recent sex work had a 1.72-fold (95% CI: 1.30-2.28; I²: 65%) and 1.59-fold (95% CI: 1.29-1.96; I²: 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; I²: 68%) but not men (IRR: 1.43; 95% CI: 0.92-2.22; I²: 51%), and was associated with HCV acquisition among men (IRR: 1.51; 95% CI: 1.22-1.87; I²: 0%), but not women (IRR: 1.26; 95% CI: 0.90-1.77; I²: 55%). For lifetime behaviours, only male-with-male sex was associated with HIV acquisition (IRR: 2.44; 95% CI: 1.18-5.02; I² = 87%). Results from Egger's tests did not provide evidence of asymmetry bias for our pooled estimates, while I² 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.
SN - 2589-5370
ER -