High Prevalence of Sexually Transmitted Infections Among Young Peruvians Who Have Sexual Intercourse With Foreign Travelers in Cuzco
Part of the data reported in this article was presented as a poster at the 9th Conference of the International Society of Travel Medicine in Lisbon, Portugal. May 1-5, 2005.
Miguel M. Cabada, MD, 6315 Central City Boulevard, Apartment 116, Galveston, TX 77551, USA. E-mail address: firstname.lastname@example.org
Background Sexual networking in popular tourist destinations is a problem worldwide. In Peru, locals sexually interacting with travelers bridge high-risk groups, the general population, and travelers.
Methods A cross-sectional study was conducted in Cuzco about sexual behavior among young Peruvians who admitted having sex with travelers. A subgroup of the participants had serologic testing for Chlamydia trachomatis, Herpes simplex virus (HSV) type 2, and Treponema pallidum.
Results Eighty-eight subjects volunteered for blood sampling. Their mean age was 22.9 years (±4.1) and 53.4% were male. The majority were single (86.2%), but 12.6% had a stable relationship. The median number of sexual partners in the 3 months prior to the study was 2 [interquartile range (IQR): 1–4]. During that period, 43.1% reported foreign partners, 28.4% reported foreign and Peruvian partners, 17% reported Peruvian partners, and the remaining 11.5% reported combinations of Peruvian, foreign, and sex workers partners. The median number of foreign partners in the 12-month period prior to the study was 4 (IQR: 2–8). Only 25.3% reported consistent condom use. Alcohol (69%) and drugs (36.8%) were commonly used before sexual activity. Seventy-eight percent tested positive for HSV type 2, 25% for C trachomatis, and 1.1% for T pallidum.
Conclusions The core group of young Peruvians we report on demonstrated a high-risk sexual behavior and a high prevalence of sexually transmitted infections. Our results underscore the need for education on safer sex practices among this group and among travelers.
Commercial and noncommercial sex networks have been described in tourist destinations.1–7 These networks bridge high-risk groups, the general population, and travelers. The consequences include the transmission and spread of human immunodeficiency virus (HIV) and sexually transmitted infections (STI), including resistant strains, across international borders.8,9 However, few reports focus on the impact of this sexual contact with travelers on the epidemiology of STI in the host countries. Cuzco is the main tourist destination in Peru. The nearby Machu Picchu Inca ruins started experiencing its first surged of tourists inflow in the 1960s. Since then, the number of tourists has increased every year, from 35,000 in 1963 to more than 730,000 in 2007.10,11 Along with tourists arriving to Cuzco, a new risk group for STI started to appear among the local population. These were men seeking female tourists to engage in sexual relationships in hopes of obtaining material benefits. The local population called them “bricheros.” They used to dress in traditional Andean attires and claimed to be descendents of the Incas. This “incanismo,” as described by Michael Hill, vindicated their proud Inca ascent and served as a way to offset social exclusion and market themselves among travelers.12
With the second boom of tourism in Cuzco in the early 1990s, increasing numbers of young Peruvians in search of employment have gathered in Cuzco. Many of these people work in the tourism industry and find themselves involved in casual sex with travelers.13 New risk groups added to the scene included women, homosexual men, and western looking men (as opposed to the indigenous looking “brichero”). Although none of the people in these groups would recognize themselves as bricheros, they would point out others within their group as such.14 This lack of self-identification points toward a poor insight on risk behavior and a decay of incanismo among young people in Cuzco.
At the present time, the term brichero (or the feminine “brichera”) is used indistinctly to name young Peruvians engaging in sexual intercourse with travelers. The present cross-sectional study describes the sexual behavior and the prevalence of markers for STI among young Peruvians engaging in casual sex with travelers.
Between August and November 2001, a cross-sectional study was conducted in Cuzco, Peru, about sexual behavior in travelers and young Peruvians. Peruvian subjects between 18 and 50 years of age, found in bars and discotheques around the main square of Cuzco city, who admitted sexual intercourse with foreign travelers within the 12-month period prior to the date of the enrollment, were invited to participate. The sample was obtained using the snowball method. Two individuals known in the local scene were contacted and trained to perform the study enrollment procedures.
A total of 171 local subjects met the inclusion criteria and were included in the study. Participants were asked to fill out a self-administered questionnaire exploring data on demographics and sexual behavior. The first 100 subjects who participated in the study were invited to submit blood samples for serologic testing for STI. Aliquots of each sample were stored at −70°C for future testing. Only data from those who agreed to submit a blood sample are reported.
Commercial enzyme linked immunosorbent assays (ELISA) were used to measure immunoglobulin G (IgG) binding to Chlamydia trachomatis (ClinPro International Co. LLC, CA, USA), Herpes simplex virus (HSV) type 2 (ClinPro International Co. LLC, CA, USA), and Treponema pallidum (ClinPro International Co. LLC, CA, USA) at the Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia in Lima, Peru.
Data were analyzed using SPSS 9.0.0 for Windows (Copyright SPSS Inc., 1989–1999). The study protocol and the consent forms were reviewed and approved by the Peruvian National Institute of Health Ethics Committee. Written informed consent was obtained from all participants in this study.
Eighty-eight of the 100 subjects agreed to blood sampling. The mean age of the participants was 22.9 years (±4.1) and more than a half (53.4%) of them were male. Participants were most commonly born in Cuzco (42.4%) and Lima (30.6%). Most (89.3%) had Cuzco as their permanent place of residence.
The majority of the participants were single (86.2%), but 12.6% had a partner in a stable relationship. Most participants (72.6%) were employed. Among these, 71.2% were employed in jobs related to the entertainment of tourists such as bars and discotheques (Table 1).
Table 1. Demographic characteristics of the participants
|Age (mean) (n*= 79)||22.9 (SD: 4.1)|
|Gender (n= 88)|| |
| Male||47 (53.4)|
| Female||41 (46.6)|
|City of origin (n= 85)|| |
| Cuzco||36 (42.4)|
| Lima||26 (30.6)|
| Other cities||23 (27.0)|
|Permanent residence (n= 84)|| |
| Cuzco||75 (89.3)|
| Lima||5 (6.0)|
| Other cities||4 (4.7)|
|Marital status (n= 87)|| |
| Single||75 (86.2)|
| Married/stable relationship||11 (12.6)|
| Divorced||1 (1.1)|
|Type of education completed (n= 88)|| |
| Technical||31 (35.2)|
| University||29 (33.0)|
| High school||26 (29.5)|
| Primary school||2 (2.3)|
|Occupational status (n= 84)|| |
| Employed||61 (72.6)|
| Entrepreneur||14 (16.7)|
| Unemployed||9 (10.7)|
|Type of employment (n= 59)|| |
| Puller†||17 (28.8)|
| Other bar/discotheque employee||8 (13.7)|
| Barman||7 (11.8)|
| Waitress/waiter||6 (10.1)|
| Tour guide/agency employee||2 (3.4)|
| Bouncer||2 (3.4)|
| Other/not related to tourism industry||17 (28.8)|
|Sexual orientation (n= 81)|| |
| Heterosexual||69 (85.2)|
| Bisexual||8 (9.9)|
| Homosexual||4 (4.9)|
The median number of new sexual partners in the 3-month period before the study was 2 [interquartile range (IQR): 1–4]. During the same period, 43.1% reported only foreign partners, 28.4% reported foreign and Peruvian partners, 17% reported only Peruvian partners, 5.7% reported Peruvian, foreign, and sex worker partners, and 2.3% reported sex worker and foreign partners. The remaining 3.4% did not disclose their type of partners. The median number of foreign partners during the 12-month period before the study was 4 (IQR: 2–8). Only 25.3% reported consistent condom use. Most participants (69%) disclosed having sexual activity under the influence of alcohol and 36.8% had it under the influence of illicit drugs. One third (32.1%) reported symptoms compatible with STI in the past. Almost half (42.5%) of the women reported abnormal vaginal discharge, 5% reported abnormal vaginal discharge and inguinal buboes, and 2.5% reported genital ulcers. While 12.7% of men reported abnormal urethral secretion and 4.2% reported genital ulcers.
When stratifying according to gender, men reported more sexual partners and more foreign partners than women but reported having had symptoms compatible with STI less often. Although women reported having had only foreign partners more often than men in the 3 months prior to the study (50.0% vs 35.5%) and less often having had sexual intercourse under the influence of drugs (26.8% vs 45.6%), the differences were not statistically significant. Only men reported having intercourse with sex workers (Table 2).
Table 2. Comparison of sexual behavior characteristic and prevalence of STI between men and women
|Had three or more new sexual partners in the previous 3 months||27/45||9/38||4.83 (1.69–14.19)||0.00|
|Had only foreign partners in the previous 3 months||16/45||22/40||0.45 (0.17–1.18)||0.11|
|Had five or more foreign partners in the previous 12 months||27/47||14/41||2.60 (1.01–6.82)||0.04|
|Had sexual intercourse under the influence of alcohol||35/46||25/41||2.04 (0.74–5.69)||0.19|
|Had sexual intercourse under the influence of drugs||21/46||11/41||2.29 (0.85–6.25)||0.11|
|Reported inconsistent condom use||34/47||31/40||0.76 (0.25–2.24)||0.76|
|Had symptoms compatible with STI||8/47||20/40||0.21 (0.07–0.60)||0.00|
|Positive ELISA for Chlamydia trachomatis||12/47||10/41||1.06 (0.36–3.12)||0.90|
|Positive ELISA for Herpes simplex type 2||39/47||30/41||1.79 (0.57–5.64)||0.39|
|Positive ELISA for Treponema pallidum||1/47||0/41||NS||NS|
Seventy-nine percent (79.5%) had at least one positive IgG ELISA test. More than three quarters (78.4%) tested positive for HSV type 2, 25% tested positive for C trachomatis, and 1.1% tested positive for T pallidum. Those born in Lima tested positive for HSV type 2 significantly less often than those born in other Peruvian cities (odds ratio = 0.25 (0.07–0.84)). No significant associations were noted between antibodies to STI and other demographic variables.
We report the characteristics of the sexual behavior and the prevalence of antibodies to STI in Peruvians who engage in sexual activity with foreign travelers in Cuzco. Four characteristics of this group deserve special attention including a high turnover of sexual partners, the sexual interaction with different risk-level groups, the gender differences in sexual behavior, and a high seroprevalence of STI.
One of the most important behavioral determinants of the risk for STI, including HIV, is the number of sexual partners.15 Data on lifetime number of partners were not collected, but the number of current partners and the rate of partner acquisition maybe more precise determinants of risk. The high number of partners reported by the participants in the 3-month and 12-month periods before the study put them among the highest risk categories. Of note, the number of foreign partners in the 12 months prior to the study was quite high. The overall number of partners in the 12 months prior to the study might have been even higher if we consider that a significant proportion of subjects also had local and sex worker partners.
This group of local young people plays an important role in sexual networking, given their sexual interaction with local population, travelers, and sex workers. The level of complexity of this network has not yet been studied. Factors that likely play a role are the geographic mobility of the interacting groups, the interaction between different risk groups, the very low rate of consistent condom use, and the high rate of alcohol and drug use.
Geographically, mobile groups are known to be at a higher risk for STI/HIV acquisition and transmission.16–18 In Cuzco, travelers and locals interacting with them form two different geographically mobile populations. Travelers, on one hand, usually visit several places in the region and can potentially interact with other networks. Local people, on the other hand, move with traveler influx. In the group studied, only 42% were originally from Cuzco and more than 10% did not have Cuzco as their primary place of residence.
Almost 13% reported having stable partners in addition to their casual partners. The stable partners of these subjects end up sharing risk without sharing the behavior. This is not an uncommon observation in Peru and helps explain how monogamous women acquire STI/HIV through their polygamous partners.19–22
Three quarters of the participants reported inconsistent or no condom use. This rate of condom use is consistent with rates reported in the general population in Peru23 and is significantly lower than the rates reported by sex workers.24–26 The differences might be explained by the fact that sex workers are usually targeted in preventive interventions, whereas the study subjects are not a recognized risk group. Another explanation might be the false perception of low risk. Only a few subjects interviewed by Bauer in Cuzco on 2006 would acknowledge being part of a risk group.14 Low rates of condom use and the common alcohol and drug use before sexual activity have been associated with riskier sexual intercourse and increased risk for STI/HIV in multiple studies.27
Studies done in the Peruvian general population have shown that while women’s mean number of partners was less than one during the previous year, near 20% of women reported that their male partners had sex with sex workers or another woman in the same period.23 These differences are somewhat accepted in the Peruvian society and were maintained by male participants, who had more partners and interacted with more risk groups.
Although the number of partners reported by women was lower than the number reported by men, this number was considerably higher than the number of partners reported by Peruvian women in the general population.28 Contact with people with other sexual behavior patterns, change in acceptable sexual conduct, social exclusion, or compelling economic needs may explain at least in part this difference with the general population.
Most participants were young adults with higher education working in jobs like bartenders or waiters. The lack of well-paying work opportunities for young people in developing countries is not an exclusive problem of Peru. But in Cuzco, where casual sexual activity, alcohol, and drugs are widely available, young people in this socioeconomic situation become vulnerable. Similar social inequities among core groups drive STI/HIV epidemics in many parts of the world.29
Young Peruvians engaging in sex with travelers are a vulnerable population with limited access to health care, prevention information, and capacity to negotiate in social relationships. This marginal group is forced to interact with an economically privileged group. Participants volunteered information about the existence of various degrees of coercion by business owners, who forced their employees to drink and dance with travelers as a way of increasing profits.
Although male participants exhibited riskier behavior, the seroprevalence of STI antibodies was not significantly different among men and women. In contrast, other studies on seroprevalence of C trachomatis, HSV type 2, and T pallidum showed higher rates among women despite less riskier behavior.23
The seroprevalence HSV type 2 antibodies was remarkably high. Studies suggest that the prevalence of HSV type 2 is increasing in developing countries,30 typically where HIV/AIDS is a serious problem.31–33 The relationship between HSV and HIV transmission34,35 is of concern in the population studied since other multiple risk factors for HIV infection are also present.
In conclusion, this group of young Peruvians exhibited high-risk sexual behavior and high STI seroprevalence. Their interaction with different groups underscores the importance that they have in transmitting STI inside and outside Peru. This group, as well as other similar groups in developing countries, needs to be recognized as a marginal vulnerable group and included in preventive interventions by the local health authorities.
We would like to thank our field workers Ms. Anahi Cardona, Ms. Fabiola Vega, Ms. Erika Camacho, and Mr. Fedor Yancaya for their tireless efforts to assure the quality of the data gathered for the study. We are also grateful to Dr Manuel Montoya for helping in the coordination of the logistics of the study and to Dr A. Clinton White for critically reviewing the final version of the article. This study was partially funded by the Peruvian National Institute of Health and the International Society of Travel Medicine.
Declaration of Interests
The authors state that they have no conflicts of interest.