Introduction

11 million people are incarcerated worldwide, and it is estimated that 3-7% of this population are women. The prevalence of HIV, STD, hepatitis B and C, and tuberculosis in the prison population is from two to ten times greater, and in some cases even 50 times higher than it is in the community. Specific data about the female prison population is scarce, although it is believed to be growing, as is the male population, and for the same reasons¹-³.

The overall inmate population is increasing rapidly, which makes it essential to prepare interventions for HIV and STD in prison settings, both for inmates and for their families and relatives¹,⁴.

There are no prevention, treatment and care programmes for HIV and STD in prisons and other detention centres in regions such as Latin America and Africa. Few countries apply programmes to the prison setting and there are many that do not link existing programmes in prisons with national campaigns against AIDs, tuberculosis or public health programmes. Few prisons provide adequate services to female inmates, although they are aware that they form a special population given the possibility of STD and pregnancy⁵-⁷.

Women, especially adolescent girls, may run the risk of infection from HIV and STD in prison, due to exposure to situations of violence, alcohol or drug use and lack of medical advice, all of which make it important not only to be aware of this situation of but also to implement preventive actions for HIV and STD in this special population⁸-¹¹.

There are few studies that evaluate this problem in the female prison population. Most research focuses on male populations, given that there are more male inmates with a consequently greater impact on the overall population¹²,¹³.

We carried out a study with information gathered in 2016 at all Peruvian prisons, with a view to discovering the factors associated with STD amongst female inmates.

Material and method

A retrospective study of secondary sources was carried out, using the public database of the Peruvian National Institute of Statistics and Information Technology (INEI) of the first Peruvian National Prison Census of 2016¹⁴, in collaboration with the General Directorate of Criminal and Penal Policies and the National Institute of Prisons (INPE).

The sample consisted of 4,574 inmates from 67 prisons in Peru, located in 23 regions of the country and the Constitutional Province of Callao, with a coverage of 98.8% of the prison population. The variables that had some relevance to the issue were selected while the others related to factors associated with STD were organised.

Results

The study was carried out on the open database of the INPE, consisting of 4,574 inmates in all the prisons in the country. It includes all the answers marked as affirmative in the questionnaire.

The population was made up mostly of young women (59.40% between 20 and 40 years of age), with high rates of a background of tuberculosis (7.25%), consumption of drugs (32.39%) and alcohol (67.68%), mostly heterosexual (97.66%) and with no stable partner (65.37%) (see answers in Table 1).

The factors associated with STD can be seen in Table 2.

A statistically significant association (≤0.05) was observed in the following variables: tuberculosis, HIV/AIDS, hepatitis, drug use, type of alcohol and sexual orientation, with the likelihood of presenting an STD in the population studied.

Table 3 shows the analysis of the association of factors linked to the presence of STD amongst the Peruvian female prison population in the multiple regression model, where it was found that the factors of tuberculosis (PR: 2.64; CI 95%, 1.32-5.26), HIV/AIDS (PR 6.54, CI 95% 1.52-28.18), hepatitis (PR: 4.01; CI 95%, 1.23-13.11) and drug use (PR: 2.44; CI 95%, 1.32-4.52), are statistically related (P ≤0.05).

Discussion

The data of the population that we studied showed that tuberculosis, HIV/AIDS, hepatitis and drug use variables are significantly related in the multivariate model to the likelihood of the Peruvian female prison population presenting STD.

Tuberculosis is a common problem in the prison population as a whole, and is frequently associated with STDs in several studies found in the bibliography. Factors such as prison overcrowding, lack of awareness of the mechanisms of transmission, poverty and drug abuse have frequently been related to the coexistence of both diseases in many articles published in Europe, Asia and Latin America. It is important to point out that according to some studies¹⁵,¹⁶, inmates showed a positive association between tuberculosis and HIV infection.

HIV/AIDS is the health diagnosis most frequently associated with the presence of sexually transmitted diseases in the prison population. Many studies have established a relationship between both diseases, especially in prisons. Another point to note is that where women are concerned, there are added problematic factors such as co-infection from vertical transmission in the case of pregnant inmates, lack of access to health services in prison and the lack of health policies for services and control programmes for STDs. Such a finding should be seen as a serious warning of the need to establish combined control measures for both HIV/AIDS and STDs¹⁷-²².

Viral hepatitis B and C are diseases associated with sexual transmission, with IDU and with trans-placental transmission (especially hepatitis B). The survey we used does not discriminate between the types of hepatitis, but a number of studies have come to the same conclusion, in that the presence of hepatitis, especially type B, is found as an independent risk factor in the prison population, especially amongst women²³-²⁵.

In Peru there is no data about intravenous drug use, which aggravates the problem of sexually transmitted and blood-borne diseases, such as hepatitis B and HIV. However, what is noticeable is that the use of inhaled drugs such as those derived from cocaine alkaloid may be significantly associated with STDs, due to reduced psychological barriers, exposure to unprotected sexual behaviours and sex trafficking, which have been observed even in exclusively female prisons. Many studies carried out specifically in countries where IDU (opiates and non-opiates) is widespread in prison settings show that there is an association between drug use and a higher risk of STD transmission, especially in the younger sectors of the prison population, making it an important factor to be borne in mind for public policies to control STD, especially in provisional detention centres²⁶-²⁹.

Finally, we assessed sexual orientation as a possible factor in presenting STD due to the fact that analysis in the community has not been recognised as an independent factor. However, we believe that, as in other studies, it merits special attention as a part of women's health in controlling STDs, because of the potential inequalities in accessing healthcare services that exist for lesbians, gays, transgender persons and bisexuals (LGTB) in prisons, as is the case in the community³⁰.

Some limitations of this study are related to problems commonly associated with open database studies: the questions were not specifically designed to study the relationship between the factors and STDs; and the questionnaires were carried out in the prison setting, which may have generated a lack of trust in answering questions that may be regarded as intimate. However, we do feel that we have established some interesting associations for exploration in further studies.