Figures
Citation: Curioso WH, Blas MM, Nodell B, Alva IE, Kurth AE (2007) Opportunities for Providing Web-Based Interventions to Prevent Sexually Transmitted Infections in Peru. PLoS Med 4(2): e11. https://doi.org/10.1371/journal.pmed.0040011
Published: February 27, 2007
Copyright: © 2007 Curioso et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This article was supported in part by the Amauta Health Informatics Research and Training Program, a Fogarty International Center/NIH funded grant (D43TW007551), and the Fogarty/Ellison Fellowship, an NIH training grant (D43TW00007).
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: MSM, men who have sex with men; STI, sexually transmitted infection
HIV is one of the biggest infectious killers worldwide, causing 8,000 deaths a day in 2005 [1]. In Latin America, an estimated 1.8 million people are living with HIV [1], and in 2005, about 66,000 people died of AIDS and 200,000 were newly infected with HIV [1].
In Peru, the HIV/AIDS epidemic has largely been concentrated among men who have sex with men (MSM) and female sex workers [2,3]. The seroprevalence rate for MSM is 10%–22% [3–5], compared to 0.1%–0.4% for the general population [6]. The prevalence of other sexually transmitted infections (STIs) among the MSM population is also high: 13.4% for syphilis and 46.3% for herpes simplex virus type 2 [3].
Even though the HIV/AIDS epidemic is confined to high-risk groups, there is significant risk for a wider HIV spread. A 2005 study in young males from socioeconomically disadvantaged populations showed that at least 14.2% of them had a male sexual partner in the last six months, and 86.3% of those who had a male sexual partner also had female partners in the same period [7]. Most of these young men's sexual encounters with male partners (56.9%) and female partners (84.2%) were unprotected [7].
The Revolution of Internet Cafes (Cabinas Públicas) in Peru
One way of facilitating high-risk sexual encounters is through the Internet. In Peru, as in other cities of the developing world, Internet access is widely available through Internet cafes (cabinas públicas), small-scale storefront operations that offer low-cost and reliable connections. In Latin America, Internet cafes have been growing since around 1998, when competition in the telecommunications sector decreased the prices of dedicated phone lines [8].
In Peru, by February 2005, more than 10,000 cabinas públicas (at least 6,000 in Lima) were distributed throughout the country [9]. Peru is one of the countries with the highest number of Internet users in public places. By January 2006, there were an estimated 10 million Internet users in Peru [10].
Cabinas are characterized by their low prices—an average of 15–30 cents (US) per hour—and relatively efficient connectivity [8,11]. The cabinas are the result of thousands of commercial initiatives of small informal entrepreneurs, and they offer other services as needed such as faxing, scanning, printing, photocopying, text editing, CD/DVD-writing, long-distance calls, and videoconferencing; some sell food and drinks (Figure 1). Cabinas are user-friendly and even unskilled users can rent a computer and, in most cases, receive basic assistance in operating computer programs [8]. Some are open 24 hours a day [12], and it is common to find cabinas even in poor urban slums.
In a 2000 national survey of 1,752 people (range 15–60 years, mean = 22.7 years) in five major Peruvian cities, 80.4% of Internet users (defined as those accessing the Internet at least once a week) said they accessed the Internet through cabinas públicas [13]. More recently, in a 2006 survey conducted by The APOYO Group, a business consulting firm based in Lima, 83% of Internet users in Lima (defined as those accessing the Internet at least once a month) accessed the Internet through cabinas públicas [14].
Looking for Sex on the Internet
The wide pool of potential sex partners found online, coupled with ease of travel, are factors that could increase the spread of STIs [15,16], especially among MSM, for whom the Internet provides a new meeting venue for sex partners [17–19]. Recent studies show an association between very high-risk sexual behavior and meeting sex partners online [19,20]. MSM may find this virtual form of sex-seeking appealing because it offers anonymity, privacy, safety, minimal cost, and easy access at any time [21].
The ease of finding sex partners online increases STI and HIV risk, according to previous research [15,22,23]. Wong et al. reported that in San Francisco, having sex with an Internet partner is a risk factor for syphilis in MSM (odds ratio = 2.1 [95% confidence interval, 1.0–4.3]) [24]. The data available about this phenomenon are mainly limited to the United States [25–33] and other parts of the world such as the Netherlands [34,35], the United Kingdom [20,36–38], Sweden [39], and Canada [40,41]. An outbreak of syphilis in MSM in San Francisco, for example, was traced to an Internet chat room where the infected men had first met [15].
In Latin America, to our knowledge, only two studies have examined the role of the Internet in facilitating sexual contacts, and both were done in Peru. The first one, a study involving 100 HIV-positive patients who attended an HIV clinic in Lima, found that among men who reported seeking sex on the Internet, 94% were MSM and the remaining 6% were heterosexual (p = 0.032); all five respondents who reported having had sex with a partner found online were MSM [42].
The second study, by Blas et al., advertised an online survey through banner ads displayed on a popular Peruvian gay Web site [43]. The researchers received 1,124 completed surveys during the three months the survey was advertised. Cabinas públicas were reported as the main place of Internet access among 58% of the participants. Regarding Internet sex-seeking behaviors, 82% of those who reported that they were HIV negative or whose HIV status was unknown sought sex on the Internet, and 67% had sex with an Internet partner during the last year. Among 52 HIV-positive participants, 77% sought sex and 67% had sex with an Internet partner during the last year (personal communication, M. Blas, January 29, 2007).
Cabinas Públicas as a Venue for Cybersex and Real Sex
A particular feature of some cabinas (Figure 1) is the availability of private modules so that clients can have sex on-site or arrange privacy for cybersex using Web cams to engage in sexual self-stimulation while online with another person. In the online survey conducted by Blas et al. [43], 1% (10/1,112) of the respondents (mean 26 years) reported having had their last sexual intercourse inside a private module of an Internet cafe. Of those who responded, nine out of ten had anal sex (only four used a condom), and one out of ten had oral sex without a condom. Of those who had anal sex, four out of nine had a casual partner, three out of nine an anonymous partner, and two out of nine a stable partner. All last sexual partners were males and all were met on the Internet.
Whether sexual encounters in cabinas are associated with HIV/STI incidence in Peru remains an open question that requires further investigation.
Opportunities for Providing Web-Based Interventions
Given the possible association between HIV/STI transmission and the high level of Internet use by MSM in Peru, cabinas públicas are a logical place to deliver Web-based interventions. Cabinas also may be an effective means for delivering low-cost prevention messages to a great number of people, especially those who are not being reached using more traditional methods [43–45]. In Lima, traditional MSM outreach has been done face-to-face by peers in streets, discotheques, bathhouses, and bars.
Currently, two Peruvian institutions, Asociación Vía Libre and Asociación Civil Impacta conduct weekly counseling sessions by chat targeted to MSM from GayPeru.com (http://www.gayperu.com) (personal communication, M. Blas, January 29, 2007). A few people reported having had their last sexual intercourse inside a private module of an Internet cafe, according to our last survey (personal communication, M. Blas, January 29, 2007). It may be valuable to test the effectiveness of a prevention strategy that is based in the cabinas themselves. For example, cabina owners could be encouraged to sell or distribute condoms and display health referral information on HIV/STIs. The Web-based interventions also have the ability to reinforce STI information obtained in clinic settings among those who seek STI testing [46,47].
We are planning to carry out an Internet-based intervention for MSM to facilitate HIV/STI screening, early diagnosis, and treatment. Such strategies have been used in the US to increase access to STI testing [48–50], and in the Netherlands to negotiate safe sex practices among single gay men and their partners [51].
While such Web-based preventions are promising, three significant barriers remain: (1) It is unclear whether participants in Peru would use Web-based prevention interventions; (2) Some populations (e.g., those who are illiterate) may be hard to reach using Internet-based techniques; and (3) It is not proven whether Web-based prevention interventions would work in Peru (though there is evidence of their effectiveness in other parts of the world) [26,51–53].
Conclusion
The unique popularity of cabinas públicas in Peru, even in poor communities with no modern infrastructure, opens new possibilities to develop and evaluate Web-based prevention and intervention programs for HIV/STIs. In theory, Web-based interventions can be delivered at low cost, and can be accessed by a large number of participants, and they might be a good way to target an MSM community that may not easily be reachable via traditional health campaigns. Future research should be undertaken to establish the acceptability and efficacy of Internet-delivered HIV/STI interventions in Peru and other resource-constrained settings.
Supplementary Information
Alternative Language Abstract S1. Spanish translation of the abstract by IEA
https://doi.org/10.1371/journal.pmed.0040011.sd001
(19 KB DOC).
Figure S1. Screenshot of a random chat session in Spanish found at latinchat.com on November 2005.
“Kenny,” a person from Lima, is looking for “actives” (insertive anal sexual partners).
https://doi.org/10.1371/journal.pmed.0040011.sg001
(163 KB PPT).
References
- 1.
Joint United Nations Programme on HIV/AIDS (2005) UNAIDS/WHO AIDS epidemic update: Special report on HIV prevention. Geneva: UNAIDS. Available: http://www.unaids.org/epi/2005/doc/EPIupdate2005_html_en/epi05_00_en.htm. Accessed 29 January 2007.
- 2.
United States Agency for International Development (2005) HIV/AIDS health profile: Peru. Available: http://www.usaid.gov/our_work/global_health/aids/Countries/lac/peru_05.pdf. Accessed 29 January 2007.
- 3.
Guanira J, Pun M, Manrique H, Lama J, Galvan R, et al. (2004) Second generation of HIV sentinel surveillance among men who have sex with men in Peru during 2002. Abstract WePeC6162. 15th International AIDS Conference; 11–16 July 2004; Bangkok, Thailand. Available: http://www.iasociety.org/abstract/show.asp?abstract_id=2169345. Accessed 29 January 2007.
- 4.
Jorge S, Russell K, Carcamo C, Negrete M, Paredes A, et al. (2000) HIV sentinel surveillance for men who have sex with men in Peru. Abstract ThOrC717. 13th International AIDS Conference; 9–14 July 2000; Durban, South Africa. Available: http://www.aegis.org/conferences/iac/2000/ThOrC717.html. Accessed 29 January 2007.
- 5. Tabet S, Sanchez J, Lama J, Goicochea P, Campos P, et al. (2002) HIV, syphilis and heterosexual bridging among Peruvian men who have sex with men. Aids 16: 1271–1277.
- 6.
Carcamo C, Hughes J, Garcia P, Campos P, Garnett G, et al. (2003) Sexually transmitted disease (STD) prevalences from the 2002 national household-based general population survey of young urban adults in Peru [poster]. 15th Biennal Meeting of the International Society for Sexually Transmitted Diseases Research (ISSTDR) Conference; 27–30 July 2003; Ottawa, Canada. Available: http://www.upch.edu.pe/faspa/preven/abstracts/Posterabstract2.pdf. Accessed 29 January 2007.
- 7.
Konda KA, Fernandez P, Lescano AG, Klausner JD, Leon SR, et al., editors. (2005) Frequency of and factors associated with self-reported male male sex among heterosexually identified, socially marginalized men in Peru. 16th Biennial Meeting of the International Society for Sexually Transmitted Diseases Research (ISSTDR) Conference; 10–13 July 2005; Amsterdam, The Netherlands.
- 8. Fernandez-Maldonado AM (2001) The diffusion and use of information and communication technologies in Lima, Peru. Journal of Urban Technology 8: 21–43.
- 9.
Villalobos HFeb 23. 2005 [Only 22 districts regulate the use of filters.] [Article in Spanish.] El Comercio Peru. Available: http://www.elcomercioperu.com.pe/EdicionImpresa/Html/2005-02-21/ImpTemaDia0263138.html. Accessed 29 January 2007.
- 10.
EFE (2006) [Peru is the second greatest consumer of broadband in Latin America]. [Article in Spanish.]. Available: http://mouse.cl/detail.asp?story=2006/01/26/10/37/49. Accessed 29 January 2007.
- 11.
[No authors listed] (2004) [Uses and attitudes towards the Internet 2004.] [Article in Spanish.] Apoyo, Opinión y Mercado [Lima, Peru]. Available: http://www.apoyo-om.com/extranet/promocionesaom/internauta2004/Internauta.htm. Accessed 29 January 2007.
- 12.
[No authors listed] (2006) Cabinas Internet. [Article in Spanish.] Yachay. Available: http://www.yachay.com.pe/especiales/cabinas/3ba.htm. Accessed 29 January 2007.
- 13.
Proenza FJ, Bastidas-Buch R, Montero G (2000) Telecenters for socioeconomic and rural development in Latin America and the Caribbean. Inter-American Development Bank. Available: http://www.iadb.org/sds/itdev/telecenters/index.htm. Accessed 29 January 2007.
- 14.
[No authors listed] (2006) [Uses and attitudes towards the Internet 2006.] [Article in Spanish.] Apoyo, Opinión y Mercado [Lima, Peru]. Available: http://www.apoyo.com/investigacion-3044-2-0.html. Accessed 29 January 2007.
- 15. Klausner JD, Wolf W, Fischer-Ponce L, Zolt I, Katz MH (2000) Tracing a syphilis outbreak through cyberspace. JAMA 284: 447–449.
- 16. Kent C, Wolf W, Nieri G, Wong W, Klausner J, et al. (2003) Internet use and early syphilis infection among men who have sex with men, San Francisco, California, 1999–2003. MMWR Morb Mortal Wkly Rep 52: 1229–1232.
- 17. Ross MW, Tikkanen R, Mansson SA (2000) Differences between Internet samples and conventional samples of men who have sex with men: Implications for research and HIV interventions. Soc Sci Med 51: 749–758.
- 18. Ross MW, Rosser BR, Stanton J (2004) Beliefs about cybersex and Internet-mediated sex of Latino men who have Internet sex with men: Relationships with sexual practices in cybersex and in real life. AIDS Care 16: 1002–1011.
- 19. Benotsch EG, Kalichman S, Cage M (2002) Men who have met sex partners via the Internet: Prevalence, predictors, and implications for HIV prevention. Arch Sex Behav 31: 177–183.
- 20. Bolding G, Davis M, Hart G, Sherr L, Elford J (2005) Gay men who look for sex on the Internet: Is there more HIV/STI risk with online partners? AIDS 19: 961–968.
- 21. Liau A, Millett G, Marks G (2006) Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men. Sex Transm Dis 33: 576–584.
- 22. Elford J, Bolding G, Davis M, Sherr L, Hart G (2004) The Internet and HIV study: Design and methods. BMC Public Health 4: 39.
- 23. Tashima KT, Alt EN, Harwell JI, Fiebich-Perez DK, Flanigan TP (2003) Internet sex-seeking leads to acute HIV infection: A report of two cases. Int J STD AIDS 14: 285–286.
- 24. Wong W, Chaw JK, Kent CK, Klausner JD (2005) Risk factors for early syphilis among gay and bisexual men seen in an STD clinic: San Francisco, 2002–2003. Sex Transm Dis 32: 458–463.
- 25. Bull SS, McFarlane M, Rietmeijer C (2001) HIV and sexually transmitted infection risk behaviors among men seeking sex with men on-line. Am J Public Health 91: 988–989.
- 26. Bull SS, Lloyd L, Rietmeijer C, McFarlane M (2004) Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: The Smart Sex Quest Project. AIDS Care 16: 931–943.
- 27. Whittier DK, Seeley S, Lawrence JS (2004) A comparison of web- with paper-based surveys of gay and bisexual men who vacationed in a gay resort community. AIDS Educ Prev 16: 476–485.
- 28. Taylor M, Aynalem G, Smith L, Bemis C, Kenney K, et al. (2004) Correlates of Internet use to meet sex partners among men who have sex with men diagnosed with early syphilis in Los Angeles County. Sex Transm Dis 31: 552–556.
- 29. Crosby R, Mettey A (2004) A descriptive analysis of HIV risk behavior among men having sex with men attending a large sex resort. J Acquir Immune Defic Syndr 37: 1496–1499.
- 30. Rietmeijer CA, Bull SS, McFarlane M, Patnaik JL, Douglas JM, et al. (2003) Risks and benefits of the internet for populations at risk for sexually transmitted infections (STIs): Results of an STI clinic survey. Sex Transm Dis 30: 15–19.
- 31. US Centers for Disease Control and Prevention (2003) Internet use and early syphilis infection among men who have sex with men—San Francisco, California, 1999–2003. MMWR Morb Mortal Wkly Rep 52: 1229–1232.
- 32. Hirshfield S, Remien RH, Walavalkar I, Chiasson MA (2004) Crystal methamphetamine use predicts incident STD infection among men who have sex with men recruited online: A nested case-control study. J Med Internet Res 6: e41.
- 33. McFarlane M, Bull SS, Rietmeijer CA (2000) The Internet as a newly emerging risk environment for sexually transmitted diseases. JAMA 284: 443–446.
- 34. Hospers HJ, Harterink P, Van Den Hoek K, Veenstra J (2002) Chatters on the Internet: A special target group for HIV prevention. AIDS Care 14: 539–544.
- 35. Hospers HJ, Kok G, Harterink P, de Zwart O (2005) A new meeting place: Chatting on the Internet, e-dating and sexual risk behaviour among Dutch men who have sex with men. AIDS 19: 1097–1101.
- 36. Elford J, Bolding G, Sherr L (2001) Seeking sex on the Internet and sexual risk behaviour among gay men using London gyms. AIDS 15: 1409–1415.
- 37. Elford J, Bolding G, Davis M, Sherr L, Hart G (2004) Web-based behavioral surveillance among men who have sex with men: A comparison of online and offline samples in London, UK. J Acquir Immune Defic Syndr 35: 421–426.
- 38. Bolding G, Davis M, Sherr L, Hart G, Elford J (2004) Use of gay Internet sites and views about online health promotion among men who have sex with men. AIDS Care 16: 993–1001.
- 39. Tikkanen R, Ross MW (2003) Technological tearoom trade: Characteristics of Swedish men visiting gay Internet chat rooms. AIDS Educ Prev 15: 122–132.
- 40. Poon MK, Ho PT, Wong JP, Wong G, Lee R (2005) Psychosocial experiences of East and Southeast Asian men who use gay Internet chatrooms in Toronto: An implication for HIV/AIDS prevention. Ethn Health 10: 145–167.
- 41. Jayaraman GC, Read RR, Singh A (2003) Characteristics of individuals with male-to-male and heterosexually acquired infectious syphilis during an outbreak in Calgary, Alberta, Canada. Sex Transm Dis 30: 315–319.
- 42.
Alva I, Blas M, Cabello R, Garcia P (2005) Risks and benefits of Internet use among people living with HIV/AIDS in a resource-contrained setting. 3rd IAS Conference on HIV Pathogenesis and Treatment; 24–27 July 2005; Rio de Janeiro, Brazil. Available: http://www.iasociety.org/abstract/show.asp?abstract_id=2177398. Accessed 29 January 2007.
- 43.
Blas M, Alva I, Cabello R, Garcia P, Redmon M, et al. (2006) Response to an Internet survey of men who have sex with men in Peru. Mednet 2006. 11th World Congress on Internet in Medicine; 13–20 October 2006; Toronto, Canada. Available: http://www.mednetcongress.com/ocs/viewabstract.php?id=330. Accessed 29 January 2007.
- 44. Klausner JD, Levine DK, Kent CK (2004) Internet-based site-specific interventions for syphilis prevention among gay and bisexual men. AIDS Care 16: 964–970.
- 45.
(2006) New technologies and public health in developing countries: The Cell-PREVEN project. In: Murero M, Rice R, editors. The Internet and health care: Theory, research and practice. Mahwah (NJ): Lawrence Erlbaum Associates. pp. 375–393. editors.
- 46. McFarlane M, Kachur R, Klausner JD, Roland E, Cohen M (2005) Internet-based health promotion and disease control in the 8 cities: Successes, barriers, and future plans. Sex Transm Dis 32: S60–S64.
- 47.
Pequegnat W, Rosser BR, Bowen AM, Bull SS, Diclemente RJ, et al. (2006) Conducting Internet-based HIV/STD prevention survey research: Considerations in design and evaluation. AIDS Behav. E-pub 20 October 2006.
- 48. Levine DK, Scott KC, Klausner JD (2005) Online syphilis testing—Confidential and convenient. Sex Transm Dis 32: 139–141.
- 49. Gaydos CA, Dwyer K, Barnes M, Rizzo-Price PA, Wood BJ, et al. (2006) Internet-based screening for Chalmydia trachomatis to reach non-clinic populations with mailed self-administered vaginal swabs. Sex Transm Dis 33: 451–457.
- 50.
Kohn R, Williams D, Klausner JD (2005) Getting STD test results over the Internet: San Francisco, 2005. 2006 National STD Prevention Conference; 8–11 May 2006; Jacksonville, Florida, United States of America. Available: http://cdc.confex.com/cdc/std2006/techprogram/P11122.HTM. Accessed 29 January 2007.
- 51.
Davidovich U, De Wit J, Stroebe W (2006) Using the Internet to reduce risk of HIV-infection in steady relationships: A randomized controlled trial of an online tailored intervention. Mednet 2006. 11th World Congress on Internet in Medicine; Toronto, Canada; 13–20 October 2006. Available: http://www.mednetcongress.org/ocs/viewabstract.php?id=126. Accessed 29 January 2007.
- 52. Kok G, Harterink P, Vriens P, De Zwart O, Hospers HJ (2006) The Gay cruise: Developing a theory- and evidence-based Internet HIV-prevention intervention. Sex Res Soc Policy 3: 52–67.
- 53.
Roland EL (2006) Core competencies for Internet outreach to MSM: Findings from Montrose Clinic's Project CORE. 2006 National STD Prevention Conference; 8–11 May 2006; Jacksonville, Florida, United States of America. Available: http://cdc.confex.com/cdc/std2006/techprogram/P11108.HTM. Accessed 29 January 2007.