In Latin America, the interest in high-rate anaerobic (pre-)treatment of sewage using UASB reactors is steadily growing since its introduction in the mid-1980s. A 2012 survey showed that 17% of 2,734 sewage treatment plants of six countries in Latin America used UASB technology, including 32% of the 702 plants in Brazil alone for sizes up to one million population equivalent. The main advantage of UASB technology is the very low or even zero energy demand, leading to an up to 10-fold drop in operational costs compared to activated sludge. In fact, anaerobic systems produce energy-rich biogas, which, however is rarely used as an energy source thus far. A compact UASB system can be implemented in a decentralized way, also in the urban area, which makes it very costeffective compared to pond systems, for which much longer conveyance systems are required. Modern high-rate UASB reactors have a standardized design with hydraulic retention times of 6-10 hours, and BOD removal efficiencies reaching up to 70-80%. As anaerobic treatment only removes the organic pollutants, any additional requirement, e.g. for nutrient removal, requires a second treatment step. At present, many different combinations have been investigated of which several are successfully applied at full scale. Moreover, novel research results even show further perspectives for the development of cost-effective integrated anaerobic-aerobic systems for complete treatment. This chapter describes the current state-of-the-art anaerobic sewage treatment in Latin America and provides some outlooks for upcoming developments.