Análisis de los datos del acompamiento pedagógico

While it is widely accepted that HIV prevalence in prisons is higher because they concentrate individuals who are more likely to engage in risk behaviours, there is still debate on whether the prison context further increases the risk of transmission [156]. This has in contrast been well documented for TB, as unhygienic conditions, overcrowding and lack of aeration in the dorms has resulted in TB outbreaks in several prisons [158]. Outbreaks of other respiratory infections, gastro‐intestinal infections and skin rashes are often documented in prisons. It is much harder to identify the transmission of HIV within the prison setting because of its long asymptomatic period. Also, people who enter prison often go back several times in their lives making it harder to track where they acquired the virus from. Prospective studies that test inmates at their entry to prison and at their exit can allow identifying within prison transmission but these have to take into account the window period from infection to

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possible detection and are complicated to put in place. However, there are several ways in which the prison environment can modify the risk of HIV exposure.

Firstly, incarceration implies a modification and sometimes a complete interruption of the day to day interaction with intimate partners. Maintaining relationships with intimate partners while in prison will be very dependent on the regulations imposed by the authorities. In the UK, for instance, conjugal visits are not permitted. In the U.S. sex in the premises is considered a crime and access to conjugal visits is only available in a handful of States and restricted to inmates who are legally bound with their partner and who meet a list of eligibility criteria. In Australia conjugal visits are allowed and in Canada they take place in spaces designed to look like a home so that they approximate the family environment. Inmates can spend up to three days per week with their partner and family. Initially, conjugal visits were created to increase work productivity in prisons by giving inmates an incentive and to control their behaviour. Today, in certain countries, maintaining relationships and family bounds is seen as an adjuvant for a more successful re-integration into society upon release, which ultimately would result in lower recidivism rates. Restrictions to the access of conjugal visits as well as many of the tensions associated with incarceration can affect intimate relationships. Partnership dissolution as a result of incarceration has been documented and investigated by researchers in the U.S. and has been found to lead to risky sexual behaviours such as unprotected sex with multiple partners.

Secondly, the choice of potential sexual partners is modified in prison. This is at most times a single sex environment and if no conjugal visits are allowed the choice might be restricted to men. Sex work occurs in prison and is often practiced by transgender inmates or inmates who were sex workers before entering. In some prisons where access to FSW is available, partner choice might be shifted towards them. On the other hand, when no attractive options are available, incarceration can simply lead to abstinence. Not only the choice of partners but also the access to prevention measures is modified. Sex is often forbidden or officially happens only under extreme measures of security in correctional settings, so condoms can be scarce if at all available.

Additionally, prisons are a dangerous setting where sex might be used, aside than for pleasure, as a form of payment, punishment or dominance (Awofeso and Naoum, 2002), also contributing to the modification in partner choice and characteristics of sex (consensual vs. violent, protected vs. unprotected). Rape can take many forms depending on the

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motivations. It can go from a single act inflicted by a single perpetrator to multiple acts inflicted by multiple perpetrators. A recent study estimating the number of HIV infections due to rape in the U.S. correctional system stated that between 0.5% and 1.5% of inmates were raped during their stay in prison. However, obtaining information on coerced or forced sex is difficult due to the sensitivity and danger associated with reporting these events. The widespread availability of drugs in prison and circumstances under which these are sold can also modify partner choice and sexual practices. Substance abuse has repeatedly been associated with sexual risk behaviours among several populations including prison inmates [114,168,169,170]. The need to finance a drug habit has been found to lead to sex work both in the community and within prisons. In particular, IDU in prisons implies high risk of infection as it is much harder to obtain clean syringes and needles or adequate material to sterilize them than outside [156]. To our knowledge, two outbreaks associated with sharing of contaminated needles in prison have been documented [171,172] and there is strong evidence supporting a relationship between incarceration and HIV outbreaks among IDUs in Bangkok, Thailand at two time points [173,174]. Tattooing, also generally banned, is another practice commonly seen in prisons, the devices are often unhygienic and used on several people. Although it is still not clear whether it is a mode of transmission for HIV it definitely is for HBV and HCV [165].

The role played by prisons in the HIV epidemic among inmates is a key question which will be approached from several angles in this work. In Chapter 4 we characterise HIV associated behaviours among a sample of inmates in the Lurigancho prison in Peru and pay special attention to whether exposure to prison is associated with their practice. Also in that Chapter, we investigate the causal pathways leading to HIV infection among this population and include exposure to prison as one of the underlying determinants that could promote behaviours responsible for infection. In Chapter 5 we investigate this question at the prison scale by testing whether high transmission rates in Lurigancho would be consistent with the prevalence trends observed taking population movement into account. Finally, in Chapter 6 we develop a conceptual framework of HIV risk among this population based on an extensive literature review and investigate determinants of infection specific to the prison context. The section below presents an overview of the prison population in Latin America.

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The Latin American epidemic