Opportunities for Providing Web-Based Interventions to Prevent Sexually Transmitted Infections in Peru

Opportunities for Providing Web-Based Interventions to Prevent Sexually Transmitted Infections in Peru

  • Walter H Curioso, 
  • Magaly M Blas, 
  • Bobbi Nodell, 
  • Isaac E Alva, 
  • Ann E Kurth
  • Published: February 27, 2007
  • DOI: 10.1371/journal.pmed.0040011

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.

Figure 1. A typical cabina pública in Peru with private booths (Photo: Magaly Blas)


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 ( (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].


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


(19 KB DOC).

Figure S1. Screenshot of a random chat session in Spanish found at on November 2005.

“Kenny,” a person from Lima, is looking for “actives” (insertive anal sexual partners).


(163 KB PPT).


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