Response to the letter: Research on health problems in the Peruvian prison system.

To the editor,

We read the letters to the editor entitled “Respiratory diseases in Peruvian prisons” and “Anxiety and depression in Peruvian prisons” with great interest. The letters commented on our article published in the first issue of 2020 of the Spanish Journal of Prison Health. We would like to give our thanks for the comments we received, which highlight the need for more comprehensive healthcare for prison inmates in Peru.

Further study of the biological and psychosocial problems of inmates is a pressing issue, considering the high burden of disease and high risk behaviours and environments that the prison population is exposed to before, during and after imprisonment. However, in Peru there is little in the way of research on the state of health of the prison population. In order to show the original articles about health research on prisoners, we carried out an exhaustive search in PubMed. The strategy used for the search was: (detention[tiab] OR jail*[tiab] OR gaol[tiab] OR imprisonment[tiab] OR offender*[tiab] OR criminal*[tiab] OR inmate*[tiab] OR penitentiar*[tiab] OR prisons[MeSH] OR prison*[tiab]) AND (Peru*). A total of seven articles were identified-, the majority of which were about infectious diseases in the prison population and amongst women (Table 1). Five of the studies were cross-sectional, four were carried out in Lima (capital of Peru), and three studies were carried out with national data. The oldest study was published in 2013. In line with its editorial policy, the Spanish Journal of Prison Health, was the journal with the most articles published (n=3) on Peruvian prisons.

Table 1

Description of the original publications on the state of health of inmates in Peruvian prisons.

Author	Year of publication	Type of study	Objective	Main findings
Garaycochea et al.2	2013	Cross-sectional	Estimate the prevalence of sexually transmitted diseases amongst female prisoners of Chorrillos Prison in Lima, Peru.	The most prevalent aetiological agents identified in cervical and vaginal fluids were Chlamydia trachomatis in 42.3%, Gardnerella vaginalis in 24.4% and Trichomonas vaginalis in 10.1%; while the most prevalent agents in serum samples were syphilis and HIV, both at 2.2%
Campos3	2016	Descriptive study	Describe the relationship between the work of women in the trans-national chain of basic cocaine products, the women's prison of Santa Mónica in Lima, Peru and the illegal cocaine market.	Prisons and the largest criminal justice system benefit financially from the growing number of arrests for drug offences, due to the systematic blackmail of incarcerated women. The cocaine sector benefits from the imprisonment of its ex-workers.
Hernández-Vásquez et al.4	2018	Cross sectional	Evaluate the presence of drug abuse before entry into prison and identify the associated socio-demographic and family history risk factors, depending on gender, in Peruvian prisons.	The general prevalence of drug consumption prior to imprisonment was 24.4% (25.3% men and 9.1% women), prevalence is higher in the age group of 18 to 29 years (36.3% men and 14.9% women). the most commonly used drugs were: marihuana (58.2%), coca/cocaine paste or crack (40.3%) and inhalants (1%). The factors associated with consumption were: having a family that consumed drugs (59.8%), previous record of imprisonment (59.1%), being unemployed (48.4%), relationships at school with classmates who had problems with the law (46.9%), background of a family member who was imprisoned (38.4%) and a record of running away from home before 15 years of age (35.9%).
Warren et al.5	2018	Cross-sectional	To estimate the magnitude and risk of spill-over of multidrug-resistant tuberculosis (MDR-TB) in the community of a neighborhood surrounding a prison in Lima, Peru, using genetic, spatial and epidemiological information of the prisoners.	The region at risk of spill-over extends some 5.47 km outside the prison (CI of 95%: 1.38-9.63 km). Within this spill-over region, it was found that nine of the 467 non-inmate patients (35 with MDR-TB) have MDR-TB strains that are genetic matches to strains collected from current inmates with MDR-TB, compared to seven out of 1080 patients (89 with MDR-TB) outside the spill-over region (p values: 0.022 and 0.008).
Ruiz-Maza et al.6	2018	Cross-sectional	Determine the prevalence and factors associated with screening for cervical cancer using the Pap test in the prison population of Peru.	A total of 4,515 female inmates of the 67 prisons in Peru participated in the study. 69% (with an IC of 95%: 67.81-70.5) carried out cytological screening in the previous year, and were associated with possession of public health insurance (PR: 1.28; CI of 95%: 1.21-1.36), attendance at the prison health services (PR: 1.18; CI of 95%: 1.12-1.24) and having a history of cancer (PR: 1.14; CI of 95%: 1.02-1.26). Age, number of offspring, exercise and the type of prison were also factors associated with cytological screening.
Salazar de la Cuba et al.7	2019	Cross-sectional	Estimate the prevalence of self-reported tuberculosis in Peruvian prisons and the associated factors.	1,754 inmates self-reported having TB (prevalence of 2,510/100,000 inmates). Self-reported TB was associated with a younger age, being male, low educational level, not having a stable partner, prison recidivism and having family in prison. There was also a strong correlation with HIV/AIDS (adjusted Odds ratio 2.77; CI of 95%: 1.84-4.18), sexually transmitted infection (adjusted Odds ratio 2.13; CI of 95%: 1.46-3.10) and use of recreational drugs (adjusted Odds ratio 1.41; CI of 95%: 1.23-1.61.).
Vildoso-Cabrera et al.8	2019	Qualitative	Determine how the prison infrastructure guarantees the rights to health and adequate surroundings for the inmates of the Women's Prison Annex of Chorrillos.	The majority of the experts in the interview stated that the current infrastructure of the Women's Prison Annex of Chorrillos does not provide minimum healthcare services. On the other hand, the inmates unanimously stated in the interview that the conditions were critical, but the majority declared that they were willing to participate in a health education programme and make commitments to preventive medicine programmes without abandoning curative medicine.

Note: CI: confidence interval; MDR: multidrug resistant; PR: adjusted prevalence ratios; TB: tuberculosis; HIV: human immunodeficiency virus.

In general terms, more research is needed in Peru to determine the risk factors, health problems, access to healthcare services and social reintegration available to the 95,000 or more inmates currently in prison. Such evidence would enable comprehensive programs and interventions to be designed to improve general health, which is the mission of public healthcare. It is also necessary to publish research that can assess the political action taken with regard to the state of prisoners’ health. Publication of the lessons learned would contribute towards institutionalising local capacities to manage improvement and access to health of prisoners in other regions and countries.

Within this context of a need for new publications, the Spanish Journal of Prison Health is an important medium of transmission that promotes the publication of original scientific contributions on prisoners’ health at a regional and international level.