Sexual Behavior, Knowledge of STI Prevention, and Prevalence of Serum Markers for STI Among Tour Guides in Cuzco/Peru
Part of this information was presented as an abstract in the 9th Conference of the International Society of Travel Medicine.
Miguel M. Cabada, MD, Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, Lima 31, Peru. E-mail: firstname.lastname@example.org
Background Sexual behavior during travel has increasingly become a focus of travel medicine research. The perceived freedom when away from home can lead to increased casual sexual activities, often unprotected. Local sexual partners, particularly those who are in close contact with tourists due to their occupation, need to be considered more in research. The purpose of this study was to explore the sexual behavior, knowledge of STI prevention, and prevalence of serum markers of selected STIs in tour guides in Cuzco/Peru.
Methods In this cross-sectional study, 161 tour guides completed a questionnaire consisting of information on demographics, sexual behavior, and knowledge about STI prevention. Blood samples of the participants were tested for antibodies against HSV2, Chlamydia trachomatis, and Treponema pallidum using commercial enzyme-linked immunosorbent assay kits.
Results The majority of guides (65%) were sexually active during the year prior to the study and 10% had foreign partners. Consistent condom use was reported by 38.1%, but almost 42% did not use condoms. In total, 27.6% reported symptoms compatible with STI. Three quarters of the participants had previously received information on STI prevention, predominantly from health professionals. In total, 22% considered themselves at high risk for STI. Antibodies against C trachomatis were prevalent in 15%, while 88.2% were against HSV2. None had antibodies against T pallidum.
Conclusions There is an inconsistency in reported sexual behavior and reported knowledge about STI prevention. Because of the tour guides’ bridging position between potential STI carriers in tourists and the local population, the reported nonuse of condoms is of concern. The prevalence of serum markers supports this concern, which is aggravated by the potential of noncurable infections. Current sexual health education strategies seem unsatisfactory, and major modifications are highly recommended.
With the increase of tourism over the last decades, people’s sexual behavior during travel has become a topic of interest. Other areas of attention are the actual disease outcomes due to concerns about STI/HIV spread.1 Disturbing recent trends in mass tourism of young people for the express purpose of having sex and pursuing alcohol and drugs, and the subsequent increase of related health problems, have shifted the focus of some studies.2–4 Similar results on less restricted sexual behavior can be found in studies on “nightlife resort tourism” where tour operators promise freedom from social constraints and promote sexual interaction among their clients.5,6 Accepting that the experience of freedom while being away from home can lead to increased sexual activity, sometimes called “situational disinhibition,”3,7 appropriate precautions to prevent the spread of STIs in such transient situations would be warranted. However, safe sex practices are far from ideal. In general, the rate of condom use has been found to be disappointing,2,5,8–10 with some studies identifying particular concern about medical students11 and women traveling abroad.12
Tourists’ sexual encounters also include local partners.1,8,9,13,14 Considerable literature exists suggesting that romantic encounters (as opposed to sex tourism) are even expected by certain tourists to certain destinations, such as the Dominican Republic,15 Jamaica,16,17 Indonesia,18 or Ecuador.19 Local employees in hospitality and tourism who have particularly close and frequent contacts with travelers, such as tour guides, might be specially exposed to an increased risk of sexual interaction with tourists. Apart from one study on sexual behavior of white water rafting guides,20 this group has been largely ignored in academic inquiry. Insight into tourism employees’ sexual behavior is of great importance to fathom the potential risk of infection to tourists, the guides, and the guides’ local partners and to devise better intervention measures. The purpose of this study was to explore the sexual behavior and knowledge of STI prevention of tour guides in the city of Cuzco, a main tourism center in Peru, and to describe the prevalence of serum markers of selected STIs.
In February 2004, we conducted a cross-sectional study in Cuzco with tour guides attending a mandatory recertification course to work in the Machu Picchu area. Subjects 18 to 50 years old with at least 1 year of experience in the field were invited to participate regardless of their tour guide certification status before the course. Those who volunteered were asked to complete a self-administered questionnaire on demographic information, sexual behavior, and knowledge about STI prevention.
A blood sample for STI serum markers testing was drawn from all the participants. The serological tests were performed with commercial enzyme-linked immunosorbent assays (ELISA) and were aimed to detect the presence of antibodies against Type 2 Herpes simplex virus–purified antigens (ClinPro International Co. LLC, CA, USA), Chlamydia trachomatis (ClinPro International Co. LLC), and Treponema pallidum (ClinPro International Co. LLC).
Data were stored and analyzed using SPSS 9.0.0 for Windows (© SPSS Inc. 1989–1999). Means, medians, and frequencies were calculated, and univariate analysis was carried out calculating chi-square tests, odds ratios (ORs), and double-sided t-test with 95% confidence intervals. Variables with a p < 0.1 in the univariate analysis were included in a backward logistic regression model.
A lecture about infectious diseases in travelers, with emphasis on sexually transmitted infections and their prevention, was included in the certification course program. The lecture was given by M. M. C. after the study procedures were completed. The study protocol and the informed consent form were reviewed and approved by the Institutional Ethics Committee of the Universidad Peruana Cayetano Heredia.
A total of 250 guides signed up for the recertification course. From these, 161 met the inclusion criteria and volunteered for the study. The mean age of the participants was 32.5 years (±7.3) and 50.6% were female. The majority (53.4%) were single, and 42.3% had a stable partner. Cuzco city was the permanent place of residence for 67.5%, and the mean time residing in the Cuzco area was 26.2 years (±10.4). More than 81% had university education to become a tour guide. Participants’ mean time working as a tour guide was 4.6 years (±5.1), and guiding was a full-time occupation for 34.8%, while 30.4% guided part-time, and for 34.8% guiding was a sporadic occupation. Tours most commonly guided were the Inca Trail hike (74.2%), the Machu Picchu ruins (54.1%), and the city tour (51.6%). The median number of foreign languages spoken by the subjects was 1.0 [interquartile range (IQR): 1.0–2.0], English being the most commonly spoken (93.8%), followed by Italian (20.5%) and French (14.3%).
Seventy-four percent reported having received information about STI prevention in the past. Main sources of information were health care professionals (54.9%), university lectures (15.9%), and books (14.2%). Most participants considered themselves at low risk for STI acquisition (47.8%), while 22% considered themselves at high risk. The three most frequently named risk groups for STI acquisition were the general population (35.8%), those who have multiple sexual partners (27.7%), and those who do not use condoms (25.2%). More than three quarters of the participants answered that condoms should be used with any kind of partner, even with regular partners, 10.0% felt that condoms should be used only with their regular partners, 8.7% recommended the use with foreign sexual partners, casual local sexual partners, and sexual workers, 2.7% answered that they should be used only with foreign sexual partners, and 2% answered that it should be used with foreign sexual partners and sexual workers. For 96.8% of the participants, the main role assigned to condoms was the prevention of STIs. Twenty-five percent of the participants answered that they would have sexual intercourse with foreign travelers if they had the opportunity.
The majority of the participants (65.0%) were sexually active during the year prior to the study. The median number of sexual partners in that period was 2.00 (IQR: 1.00–3.00 partners). From those who were sexually active during the previous year, 10.8% had sexual intercourse with a foreign traveler; among them (n= 10), the median number of foreign sexual partners was 1.50 (IQR: 1.00–2.25 partners). Sexual intercourse with sexual workers was disclosed by 15.1% of the respondents, the median number of sexual worker partners was 1.50 (IQR: 1.00–2.25 partners). Consistent condom use was reported by 38.1% of the tour guides, 13.1% reported using condoms with more than half of their sexual contacts, 7.1% reported using them with less than half of their sexual contacts, and 41.7% reported no condom use. A minority of the sexually active participants (2.5%) reported homosexual intercourse in the previous year. Most respondents denied having sexual intercourse under the influence of alcohol (57.7%) or illicit drugs (94.6%).
Symptoms compatible with STI were reported by 27.6% (37/134). Commonly reported symptoms were abnormal vaginal secretion (15/37), abnormal penile secretion (10/37), genital ulcer (6/37), abnormal penile secretion plus genital ulcer (3/37), inguinal buboes (2/37), and abnormal vaginal secretion plus inguinal buboes (1/37).
Comparing the characteristics and behavior regarding gender, men reported more often than women that they would have sex with a traveler (p < 0.01), they had more than one sexual partner in the previous year (p < 0.01), they had sex with a traveler in the previous year (p= 0.05), they paid for sex in the previous year (p < 0.01), they used condoms in more than a half of the times (p < 0.01), and they think condoms should be used with travelers (p < 0.01). On the other hand, women reported more often than men that they considered themselves at low risk for STIs (p < 0.01) and that they had never had sex under the influence of alcohol in the previous year (p < 0.01) (Table 1).
Table 1. Comparison of the demographic and behavioral characteristics among men and women
|Mean age||32.5 (±7.3)||33.7 (±8.0)||31.2 (±6.1)||0.03|
|Have a stable sexual partner||68/161 (42.3)||38/78 (48.7)||29/80 (36.5)||0.11|
|University as highest educational level||131/161 (81.4)||60/78 (76.9)||69/80 (86.3)||0.17|
|Years working as a tour guide||4.6 (±5.1)||5.9 (±6.3)||3.0 (±2.4)||<0.01|
|Type of tours guided|
| City tour||82/159 (51.6)||45/77 (58.4)||36/79 (45.6)||0.10|
| Machu Picchu||86/159 (54.1)||46/77 (59.7)||39/79 (49.4)||0.19|
| Inca Trail||118/159 (74.2)||61/77 (79.2)||55/79 (69.6)||0.16|
|Received information regarding STIs||119/161 (73.9)||58/78 (74.4)||59/80 (73.8)||0.13|
|Health care professional provided information||62/113 (54.9)||32/54 (59.3)||28/57 (49.1)||0.28|
|Would have sex with a traveler||40/160 (25.0)||35/77 (45.5)||3/80 (3.8)||<0.01|
|Considered themselves at low risk for STIs||76/159 (47.8)||28/78 (35.9)||47/78 (60.3)||<0.01|
|Had a new sexual partner in the previous year||93/143 (65.0)||46/69 (66.7)||44/71 (62.0)||0.56|
|More than one new sexual partner in the previous year||48/93 (51.6)||33/46 (71.7)||12/44 (27.3)||<0.01|
|Had sex with a traveler in the previous year||10/93 (10.8)||7/46 (15.2)||1/44 (2.3)||0.05|
|Paid for sex in the previous year||14/93 (15.1)||13/46 (28.3)||1/44 (2.3)||<0.01|
|Used condoms in more than a half of the times||43/84 (51.2)||28/45 (62.2)||12/36 (33.3)||<0.01|
|Thought condoms should be used with travelers||26/150 (17.3)||18/76 (23.7)||8/71 (11.3)||<0.01|
|Never had sex under the influence of alcohol||75/130 (57.7)||25/63 (39.7)||50/64 (78.1)||<0.01|
|Never had sex under the influence of drugs||123/130 (94.6)||58/63 (92.1)||63/64 (98.4)||0.09|
|Reported STIs’ symptoms||37/134 (27.6)||14/63 (22.2)||23/69 (33.3)||0.15|
|Positive Chlamydia IgG antibodies||25/161 (15.5)||12/78 (15.4)||13/80 (16.3)||0.88|
|Positive Type 2 Herpes simplex IgG antibodies||142/161 (88.2)||70/78 (89.7)||69/80 (86.3)||0.49|
Variables associated with having sexual intercourse with foreign travelers in the univariate analysis and, therefore, included in the backward logistic regression model were the following: reporting jungle as place of residence (p < 0.001), guiding tours to the jungle (p= 0.001), number of languages spoken by the guide (p= 0.005), and not being eager to have sexual intercourse with foreign travelers if having the opportunity (p < 0.001). The following variables were also entered in the backward logistic regression model: being male (p= 0.059), having worked as a tour guide for 4 years or less (p < 0.065), guiding as a full-time occupation (p= 0.087), and speaking German (p= 0.088). The variables retained by the model were the following: having worked as a tour guide for 4 years or less, jungle as place of residence, and not being eager to have sexual intercourse with foreign travelers if having the opportunity. Table 2 shows the adjusted ORs for the retained variables.
Table 2. Adjusted ORs for variables associated with having sexual intercourse with foreign travelers
|Would not have sexual intercourse with foreign travelers if having the opportunity||0.17||0.02 < OR < 1.75|
|Jungle as place of residence||0.06||0.01 < OR < 0.81|
|Worked as a tour guide for 4 years or less||0.17||0.02 < OR < 1.76|
Chlamydia trachomatis IgG antibodies were detected in 15.5% of the participants. Those guiding more than one route [OR = 3.82 (1.24 < OR < 11.74)] and those tour guides reporting symptoms compatible with STI in the past [OR = 3.68 (1.41 < OR < 9.63)] had positive ELISA tests more often. Those reporting consistent condom use [OR = 0.12 (0.02 < OR < 0.98)] had positive ELISA tests for C trachomatis less often. A trend toward having a positive test for Chlamydia was seen among those who guide tours in the Machu Picchu ruins [OR = 2.50 (0.98 < OR < 6.37)]. No other variables were found to be associated with a positive ELISA test for C trachomatis.
Type 2 Herpes simplex IgG antibodies were detected in 88.2% of the participants. Those tour guides who had more sexual partners during the previous year had positive ELISA tests for Herpes more often than those with less sexual partners during the previous year (χ2= 18.76, p= 0.02). A trend toward having a positive ELISA test was found among those who guide hiking tours to the Inca Trail [OR = 2.62 (0.96 < OR < 7.18)] and among those who reported being sexually active during the previous year [OR = 2.66 (0.97 < OR < 7.24)]. No other variable was found to be associated with a positive ELISA test for Type 2 Herpes simplex virus. None of the participants had a positive ELISA test for T pallidum IgG antibodies.
This study attempted to investigate tour guides’ sexual behavior and knowledge on STI prevention and to describe the prevalence of selected STIs. Three areas of findings attract most interest: (1) the knowledge about condom use and their actual use, (2) the gender differences, and (3) the prevalence of serum markers with the apparently high prevalence of HSV2; each will be discussed below.
While the guides reported that condoms should be used even with their regular partner, only one third actually reported consistent condom use. Therefore, not only must it be assumed that there is the ubiquitous discrepancy between knowledge and actual behavior but the well-known limitations of self-reports on sexual issues must also be taken into account, and some may have answered these questions to conform with what seemed socially acceptable or expected by the researcher. However, the reported nonuse of condoms is of great concern because of the tour guides’ bridging position between potential STI carriers in the travelers but also in the local population (including sex workers).
Sexual behavior in general and condom use in particular have an impact on self-reported or diagnostically established health outcomes. One third of participants reporting symptoms compatible with STIs comes, therefore, as no surprise. The only surprise may be that the figures are not higher.
It is difficult to interpret the discordance between the reported past STI symptoms and the prevalence of positive serum markers for STIs evident in our study. We need to consider factors such as recall bias, rates of asymptomatic infections (especially with HSV2 and Chlamydia), the limited number of STI serum markers tested, and the limitations regarding sensitivity and specificity of the ELISA tests used. These factors may be influencing our results in different degrees, making it hazardous to try to draw conclusions regarding this issue.
There is an assumption that tour guides are always male when, in fact, the number of female guides is increasing quite rapidly. In this particular sample, they represented half of the participants. This must be taken into account when interpreting the findings, as the female approach to sexual encounters may be different due to cultural, social, religious, or other reasons. Marked gender differences in five characteristics seem to support this assumption, in that much fewer would consider sex with travelers, had a new partner, or paid for sex in the previous year and far more claimed to never having had sex under the influence of alcohol and considered themselves at low risk for STIs. However, their reported knowledge and behavior regarding condom use were much less satisfactory than those of male participants.
While none of the participants had a positive result for T pallidum, the prevalence of C trachomatis was relatively low, whereas almost 90% of participants had a positive Type 2 Herpes simplex test. Interesting, and ultimately of concern, is that while Chlamydia prevalence was low, Chlamydia can easily be treated with a single dose of antibiotics, whereas there is no cure for the highly prevalent Herpes infections. However, it has to be taken into account that the ELISA test using the total Herpes simplex antigen can have a cross-reactivity with other Herpes viruses; therefore, the high prevalence should be interpreted with some caution. Nevertheless, this finding indicates that there is a considerable potential for the spread of other STIs which may be difficult or impossible to cure, including HIV/AIDS.
The findings of this study also suggest that three quarters of the participating tour guides had received some information on STI prevention in the past. While amount, quality, and time since lapsed are unknown, the reported knowledge and subsequent behavior and the diagnostic results suggest that the information does not necessarily translate into practice. This does not come as a surprise, as the knowledge–behavior gap, particularly in relation to sexual behavior, is well-known globally.
Tour guides may play a pivotal part in the transmission of STIs. They may be indirectly involved by recommending sexual opportunities to travelers or other guides, not unlike the motorcycle taxi drivers in the Peruvian Amazon.21 But they are also directly involved by having casual sexual relations with sustainable access to at least one additional group of potential partners, that is, travelers, compared to the average person. They, therefore, represent a potentially greater source of transmission.
Despite the ubiquitous availability of sexual health education, be it sex education in schools, information through mass media as part of health campaigns, for example “safe sex,” or targeted education to inform, reduce risk, or influence behavior change, research into sexual knowledge and subsequent behavior stubbornly produces findings that indicate that either not enough is being done or health education as it is presented now is missing the point. Relating to this current study, it seems that both travelers and tour guides need more and/or improved health education. A recent study into pretravel health advice given to international travelers to Cuzco22 suggested that only one fifth received recommendations on condom use. This is not sufficient as better prepared travelers are more likely to insist on condom use when having sex with a local guide, thus not only protecting themselves but also their partner. On the other hand, with three quarters of guides claiming to have received STI prevention information at some stage, again, this could indicate an insufficient amount, no recency, or simply inappropriate information in terms of content or delivery.
The understanding of a person’s perception of risk23 is as important for planning appropriate health interventions as is an understanding of the reasons for failing to comply.24 Neither has been established yet in the target population of this study or in the area of travel health/medicine in general. Much additional research is needed to answer many yet unanswered questions and prepare the ground for effective interventions. For example, trends in sexual behavior in Peru need to be monitored25, replications with larger samples and also guides in other Peruvian tourism centers need to be conducted, alternative methods of data collection need to be employed to curb limitations of self-reports on sexual behavior, and the concept of “impulsivity”3 as a reason for unsafe sex among travelers and guides needs to be examined in more detail.
Sexual health education as it stands now does not produce the desired results. Research suggests that the knowledge–behavior gap is still the main reason for the transmission of STIs. In relation to tour guides being at the center of attention, unsafe sexual encounters with travelers add an additional source of potential infections not only for themselves but also for their local partners, in the same way as for the travelers and their respective local partners. This negative impact of tourism on the local community is of particular concern when, often for economic reasons, medical care is not sought or, in the worst case, a potentially fatal infection is contracted. This study supports numerous other international studies suggesting that current sexual health education is still insufficient, unsatisfactory, and its outcome unconvincing. A concentrated effort should be undertaken to revisit the entire area of sexual health education (content and delivery) based on more urgently needed research internationally but also in specific locations, such as in Cuzco/Peru.
The authors would like to acknowledge Dr Elsa Gonzalez for her collaboration in reviewing and editing the manuscript of this article.
Declaration of Interests
This study was funded by the 2003 Research Grants from the International Society of Travel Medicine. The authors state that they have no conflicts of interest.