When context matters: Multilevel determinants of self-reported sexually transmitted infections symptoms among men engaged in transactional sex in 26 Sub-Saharan African countries

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BACKGROUND: Men engaged in transactional sex (METS) represent a neglected key population in sub-Saharan Africa (SSA), yet little is known about their burden of sexually transmitted infections (STIs) and associated factors. This study assessed the prevalence of self-reported STIs (SR-STI) and identified individual, community, and country-level determinants among this group. METHODS: We analyzed pooled recent nationally representative Demographic and Health Survey (DHS) data from 26 SSA countries. This study included 10,128 men who reported engagement in transactional sex within the past 12 months. Weighted prevalence estimates were calculated, and multilevel logistic regression models were applied to examine individual-, community-, and country-level determinants of SR-STI symptoms, adjusting for survey year. AIC and BIC were used as comparative model selection criteria to identify the best-fitting model among the sequential multilevel models built. RESULTS: The participants’ mean (± SD) age was 29.8 (± 10.2) years. The overall weighted prevalence of SR-STIs among METS was 19.5% (95%CI: 18.3–20.7%), nearly threefold higher than among men not reporting transactional sex (7.2%; 95%CI: 6.9–7.5%; p for difference < 0.001). Prevalence varied substantially across countries, from 5.6% in Niger to 36.9% in Liberia (p < 0.001). At the individual-level, younger age, lower education, employment, risky sexual behavior, middle household wealth, heard about STI, HIV testing, and media exposure were associated with higher odds of SR-STI, while circumcision, HIV knowledge, and Christian affiliation were protective. At the community-level, men from poorer communities were less likely to report SR-STI symptoms (aOR = 0.79; 95%CI: 0.66–0.87). At the country-level, participants from Southern Africa had lower odds (aOR = 0.49; 95%CI: 0.24–0.97) compared to those in West Africa. Significant between-country and -community heterogeneity was observed, but variance decreased with the inclusion of individual and contextual predictors. CONCLUSION: SR-STIs are highly prevalent among METS in SSA, with marked heterogeneity across countries and multiple individual and structural determinants. These findings underscore the need for targeted, context-specific interventions integrating biomedical, behavioral, and structural approaches to reduce STI burden in this population.