Characterisation of a syndemic of STI symptoms, substance use and violence among incarcerated Peruvian women
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* Elena Cyrus
* Rodman Turpin
* Typhanye Dyer
* Elika Hashemi
* Sobur Ali
* Andrea Cornejo Bazo
* Antonio Morgan-Lopez
* Joy D Scheidell
* Segundo R Leon
* Michael Sciaudone
* Frederick L Altice

## Abstract

**Objectives** Despite parallel global trends of increasing incarceration rates and sexually transmitted infections (STIs) among women, STI epidemiological data for this vulnerable at-risk population are limited. The study objective was to characterise patterns of STI symptoms and explore covariates and drivers of indicating STI symptoms using syndemic theory among a population of incarcerated women in Peru.

**Methods** In a cross-sectional study, a sample of 249 incarcerated women responded to a questionnaire on substance use, depression, sexual behaviour, STI symptoms and violence, among other variables, between May and July 2015 in Santa Manica Prison (Lima, Peru). Univariate and bivariate analyses informed a latent profile analysis (LPA) and logistic regression.

**Results** Most women (93.5%) were Peruvian; 86.6% had prison sentences <5 years; the median age was 37 years (range 18–70 years); 2.6% were pregnant, 7.2% had children residing with them in prison; most women (78.7%) had a high school degree; >1/3 of the sample had ≥2 STI symptoms. The LPA analysis revealed that 39% of the sample had a ‘syndemic’ profile (co-occurrence of multiple STI symptoms, experiences of violence and substance use). Approximately 87% of women who were characterised by the syndemic profile were <50 years of age. The ‘syndemic’ profile was associated with double the prevalence of having multiple STI symptoms (≥2 symptoms: Prevalence Ratio (PR)=1.88 (95% CI 1.18, 2.99); ≥3 symptoms: PR=2.55 (95% CI 1.32, 4.93)).

**Conclusions** To address this syndemic, younger incarcerated women presenting with co-occurring STI symptoms (>2) can be clinically screened for diagnosis and treatment and assessed for substance use and risk of violence. Further research in this area may help stem and prevent deleterious health outcomes, including STIs, abuse and substance misuse, that can impact the individual and families.

*   WOMEN
*   PRISONERS
*   INFECTION

### WHAT IS ALREADY KNOWN ON THIS TOPIC

*   High rates of substance use, depression and violence among incarcerated women in Latin America, notably Peru, have been observed to increase vulnerability to sexually transmitted infections (STIs), but less is known about their syndemic effects.

*   The global rise in incarceration rates for women, driven by punitive drug policies, has been investigated primarily in the general population, leaving a gap in understanding compounded health disparities, such as STIs, among incarcerated women.

#### WHAT THIS STUDY ADDS

*   Incarcerated women engaged in substance use (illicit drug use and/or alcohol) and who experienced violence were more likely to present with multiple STI symptoms (≥2).

#### HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

*   Our study highlights the need for integrated interventions to address substance use, violence and sexual health in incarcerated women to improve health outcomes and reduce inequities in this vulnerable population.

## Introduction

Since 2000, the global incarceration rate for women has increased by 60%, contrasting the 22% increase for men. In the Latin America and Caribbean (LAC) region, this sharp rise is largely driven by punitive drug policies disproportionately impacting women.1 The LAC region currently holds a violent crime rate four times higher than the global average,2 contributing to a subsequent increase in prison populations. Some LAC countries’ prison populations have rates more than doubled. In 2020, LAC prison statistics showed that a higher percentage of women were in prison for drug offences than men, including in Peru, with a reported 66.4% female prison population.3 Specifically in Peru, the rising incarceration rates among women since 2020 are significantly influenced by stringent drug policies and socioeconomic factors. Notably, over 60% of the women in prison are incarcerated for drug-related offences, compared with approximately 17% of men in prison. Many of these women occupy low-level roles within the drug trade, such as ‘mules’ or small-scale dealers, often driven by economic necessity and lack of opportunities. Despite their minimal involvement, they often face severe legal repercussions under Peru’s punitive drug laws, which emphasise incarceration over alternative measures, though judges may take into account mitigating factors like pregnancy, breastfeeding or primary caregiver responsibilities or having experienced sexual abuse or other forms of violence.4 The excessive use of pretrial detention exacerbates this issue, with around 40% of incarcerated women awaiting trial, often for extended periods due to judicial inefficiencies. This practice disproportionately affects women, many of whom are primary caregivers, leading to broader social ramifications.

The rise in female incarceration in Peru is linked to punitive drug policies and systemic judicial disparities. Women accused of narcotics-related crimes frequently face incarceration throughout the court proceedings, with little prospect for early release or probation.5 Incarcerated women in Peru are at increased risk of substance abuse owing to multiple factors, including preprison drug use, depression and discrimination.6 7

The LAC region also has the third highest sexually transmitted infection (STI) prevalence among women globally, and rates among incarcerated subpopulations are notably high.8 STIs can have long-term and detrimental effects on cisgender women, and persistent infections may lead to increased risk for cervical, anal or head and neck cancer.9 Limited or delayed treatment for STIs contributes to the reduction in fertility and ectopic pregnancy, which is the leading cause of maternal death during the first trimester of pregnancy.10

There is a growing focus on individual behaviours and the surrounding context when examining variations in deleterious health risk behaviours across populations.2 Consequently, this paper draws from the HIV/STI syndemic risk model, where syndemic refers to the clustering of two or more diseases or health conditions within a population driven by contextual and social factors that create the conditions for their co-occurrence. The clustering results in adverse disease interactions—whether biological, social or behavioural—that worsen the health burden within affected populations.11 12 In the context of STI risk among women, relevant factors include biological influences such as genetics and chronic stress, social drivers like forced migration and physical/psychological abuse, and behavioural patterns such as illicit drug or alcohol misuse as coping mechanisms. Broader systemic issues, such as the evolving illicit drug trade, may further exacerbate these risks. Therefore, the development of appropriate interventions for this population requires moving research from a broad overview to a detailed analysis of how STI and substance use prevalence affects these incarcerated women in the LAC region.

The objective of this study is to address the gap in the extant literature by identifying factors that are associated with increased STI risk among incarcerated women and to further characterise a substance use and violence syndemic to estimate the association between syndemic membership and STI outcomes.

## Materials and methods

### Samples

For this cross-sectional study, from May to July 2015, the study team held weekly reproductive health workshops for 779 female inmates at Santa Monica Prison in Chorrillos, Lima, Peru. Interested women were assessed for eligibility, with the following criteria: ≥18 years and willing to conduct a computer-assisted self-interview (CASI). Participants received toiletry products for their involvement.

All participants consented before the study procedures, which occurred in a designated area with one prison staff member positioned outside the room. Of the 450 self-reported cisgender women from the informational sessions, 249 (55.3%) were enrolled and assigned unique IDs for this study.

The Spanish-speaking Peruvian study team obtained consent, conducted CASI and collected biological specimens. The questionnaire, programmed in Spanish, was developed and examined by the research team and the community advisory board of the Asociación Civil Impacta Salud y Educación.

### Measures

Measures were selected a priori based on the theoretical framework of substance abuse, violence and HIV/AIDS syndemic theory, particularly relevant for young women where there may be a synergistic effect of gender-based violence, high-risk sexual behaviour and alcohol and illicit drug use.

#### Demographic and sexual risk factors

The sociodemographic data comprised the participant’s age, number of live births, country of birth and education as some primary school, some secondary school and secondary school. Participants were screened for HIV/STI and asked about sex work and condom use before incarceration. Participants also reported the length of time of prison sentences and the number of young children ≤3 years old cohabitating with them in prison.

#### Intimate partner violence

The Severity of Abuse Against Women Scale13 was employed to evaluate intimate partner violence (IPV) before incarceration. This validated scale contains 47 questions with three subscales: threats of violence, acts of physical violence and sexual aggression. 37 participants stated they had no intimate relationship before incarceration; therefore, 212 women (85.1%) completed the scale. Participants rated each item as 1=never, 2=once, 3=a few times or 4=many times. For each subcategory of IPV, the total scores for threats of violence (19–76), physical violence (27–108) and sexual aggression (6–24) were computed. For descriptive analysis, participants who reported any threat or act of violence were divided into low/moderate and strong/severe threats and abuse. This categorisation was done using cut-off scores of 25 for threats of violence and 27 for physical violence based on univariate quartile analysis.7 The Cronbach’s alpha reliability values for the subscales were 0.95, 0.96 and 0.86 for threats of violence, acts of physical violence and sexual aggression, respectively.

#### Substance use

The study employed an abbreviated Drug Abuse Screening Test (DAST-10) to evaluate harmful illicit drug use and the 10-item Alcohol Use Disorders Identification Test (AUDIT) scale to evaluate hazardous drinking behaviour. DAST-10 scores ≥6 were labelled as ‘substantial/severe’ drug misuse, and scores ≥7 were labelled as ‘hazardous’ drinking.

#### STI symptoms

Questions regarding STI symptoms (ie, discharge, odour) during and before incarceration were recorded.

### Latent profile analysis

Latent profile analysis (LPA) models were used to estimate profiles based on substance use and violence indicators to group risk factors into person-centred categories. The number of profiles was determined based on the differences between log-likelihoods for adjacent models (ie, those with an adjacent number of profiles) using the Vu-Lo-Mendel-Rubin likelihood ratio test and information criteria like the Akaike information criterion and Bayesian information criterion. We also considered entropy for profile assignment certainty and identified ‘outlier profiles’ with fewer than 10 participants. To address any local independence violations, we included a term for correlated residuals in our analyses.

### Bivariate analyses

We tested for associations between latent profiles and STI symptom outcomes, as well as all covariates. Kruskal-Wallis tests were used for ordinal and continuous covariates, χ2 for binary covariates and dichotomised STI outcomes. We also present distributions of syndemic indicators and outcomes across latent profiles.

### Regression analyses

Modified Poisson regression with robust SEs assessed associations between latent profiles and STI outcomes. We estimated unadjusted models, models adjusted for age and education only and models adjusted for age, education and commercial sex work. Ordinal terms were used as age and education covariates to maximise model convergence. Associations between latent profiles and STI outcomes (2+ symptoms, 3+ symptoms) are presented.

### Missing data

Missingness for all items was low, with most items having less than 5% missing data. To address these missing data, maximum likelihood imputation was used. After imputation, all observations (n=249) were retained. To detect influential outliers, Cook’s distances and leverages were measured, and significant outliers were noted. There was also no evidence of multicollinearity between predictors and covariates in our models (all variance inflation factors <5).

## Results

### Latent profile results

Fit statistics for models with up to five latent profiles are presented (table 1). While the profile 5 model had the greatest relative improvement in log-likelihood, it also had two outlier profiles that were impossible to validly analyse. The profile 4 model was not a notable improvement in fit compared with the profile 3 model. Also, profile 3, 4 and 5 models had a similar entropy. For this reason, we proceeded with a profile 3 model for all subsequent analyses. There was mild dependence between violence items, though this was effectively addressed by incorporating terms for correlated residuals. All indicators were significantly associated with latent profiles (table 2). Profile 1 was characterised as ‘Referent’, as it demonstrated the lowest substance use and violence. Profile 2 was characterised as ‘Substance Only’, as AUDIT scores and illicit drug use proportions were relatively high, but violence was not. Profile 3 was characterised as the ‘Syndemic’ profile, as it demonstrated relatively high prevalence of all the substance use and violence indicators.

View this table:
[Table 1](http://sti.bmj.com/content/early/2025/03/11/sextrans-2024-056371/T1)

Table 1 
Comparisons between fit measures across latent profile models (n=249)

View this table:
[Table 2](http://sti.bmj.com/content/early/2025/03/11/sextrans-2024-056371/T2)

Table 2 
Mean scores (scaled in percentage) for latent profile indicators across profiles (n=249)

### Sample characteristics and bivariate results

Approximately half of the sample was between 30 and 49 years of age, and approximately a third completed secondary school (table 3); just over a tenth of the sample had a history of commercial sex work. Slightly over a third of the sample had ≥2 STI symptoms, and almost a fifth of the sample had ≥3 STI symptoms. The ‘Syndemic’ profile comprised 39% of the sample, and the ‘Substance Only’ profile comprised 15%. There was a strong association between commercial sex work and illicit substance use in post hoc analyses (online supplemental appendix 1).

### Supplementary data

[[sextrans-2024-056371supp001.pdf]](pending:yes)

View this table:
[Table 3](http://sti.bmj.com/content/early/2025/03/11/sextrans-2024-056371/T3)

Table 3 
Sociodemographics, sexual behaviour and STI symptoms across latent profiles (n=249)

### Regression results

Compared with the ‘Referent’ profile, the ‘Syndemic’ profile was associated with nearly double the prevalence of having ≥2 STI symptoms (Prevalence Ratio (PR)=1.88, 95% CI 1.18, 2.99) and over two and a half times the prevalence of having ≥3 STI symptoms (PR=2.55, 95% CI 1.32, 4.93). This association was largely unchanged when adjusting for age and education, though it was slightly attenuated (~10% decrease in estimates) when also adjusting for commercial sex work. The ‘Substance Only’ profile was similarly associated with nearly double the prevalence of having ≥2 STI symptoms (PR=1.82, 95% CI 1.01, 3.22) compared with the referent, though this was only marginally significant in adjusted models. This profile was notably not associated with having ≥3 STI symptoms (table 4).

View this table:
[Table 4](http://sti.bmj.com/content/early/2025/03/11/sextrans-2024-056371/T4)

Table 4 
Prevalence ratios and 95% CIs for associations between latent profiles and STI symptoms (n=249)

## Discussion

The LPA identified a syndemic profile—characterised by co-occurring substance use and violence (profile 3)—that was significantly associated with a higher prevalence of STI symptoms among incarcerated Peruvian women if they were in this syndemic class relative to being in a group characterised as substance only. About one-third of the sample was characterised by this syndemic profile of engaging in substance use and being exposed to violence. This association remained robust across different STI symptom thresholds (≥2 STI symptoms and ≥3 STI symptoms) after adjusting for potential confounders. This highlights the complex interplay of social (violence) and behavioural (substance use) factors contributing to STI risk in this vulnerable population.14

The syndemic profile was found to be a significant risk factor for STI symptoms. Affected individuals experienced nearly twofold higher frequency of having two or more STI symptoms and over two and a half times higher prevalence of having three or more symptoms. These findings emphasise the compounded risk of STIs in the presence of multiple adverse health behaviours and stressors, such as engaging in alcohol, illicit drug use and/or being exposed to multiple forms of violence.6 14 Incarcerated women who experienced sexual violence are at higher risk of STIs.15 The interplay between sexual violence and systemic vulnerabilities, such as limited healthcare access while imprisoned, higher exposure to high-risk environments and lack of supportive resources, intensifies the likelihood of acquiring STIs, which may or may not be diagnosed and treated. Adopting a comprehensive approach to address these issues is essential for reducing STIs and improving the overall health outcomes of incarcerated women.

Our findings reveal that women within syndemic profiles experience significantly more STI symptoms compared with those in the referent profile. This evidence underscores the severe health outcomes associated with the intersection of high substance use and violence. The ‘syndemic’ not merely captures the coexistence of these issues in time and place but interacts in a synergistic manner that exacerbates health risks of infectious diseases like STIs in vulnerable populations.16 17 For instance, women with a history of sexual assault are more likely to engage in high-risk sexual behaviours, such as unprotected sex and substance use, which can further increase their risk for STIs.18

A higher incidence of ≥2 STI symptoms was also significantly correlated with the ‘Substance Only’ profile, which is defined by high substance use but minimal violence; however, in adjusted models, this correlation was only marginally significant. This implies that although substance abuse on its own poses a sizeable risk for STI symptoms, but when combined with violence (as demonstrated by the syndemic profile), this risk is significantly increased. The relationship between substance use and STIs in incarcerated women is complex and has multiple aspects. Prior research has demonstrated that substance use is a notable determinant of STIs,19 20 primarily because it affects engagement in unsafe sexual behaviours.21 Women who consume drugs are more prone to participating in unprotected sexual intercourse, having several sexual partners and engaging in other risky behaviours that heighten the chances of transmitting STIs.6 22 The marginal significance in adjusted models implies that other variables may influence this association, potentially connected to the context of drug use. This distinction is crucial for designing interventions because, although treating drug use is necessary, violence increases the risks considerably and calls for a more tailored strategy when both are present. It also highlights the necessity of focused therapies that address the specific requirements of women who experience different combinations of co-occurring risk factors.

STIs, violence and drug abuse are disproportionately common among incarcerated women. Understanding that these disorders are syndemic can help create thorough solutions to the underlying causes of these co-occurring difficulties. This might include integrated care models, STI screening, violence prevention and treatment for substance misuse. Substance use, violence and STIs all coexist to create a complicated web of health difficulties for incarcerated women. Resources and integrated treatment strategies required to address these complex health issues adequately are frequently lacking in incarceration settings.23 By offering comprehensive treatments that concurrently address substance addiction, violence and sexual health, integrated care models might be implemented within prisons to reduce these challenges.24 These methods may enhance general health outcomes and lower the STI rates among incarcerated women. The syndemic model also assists syndromic management of STIs when diagnostics are unavailable, which may be the case in a resource-constrained prison setting.

The results have broader implications for vulnerable female groups worldwide, especially those living in similarly restricted settings. The syndemic model illustrates how drug use, violence and STIs worsen women’s health inequities. Comprehensive public health policies beyond compartmentalised approaches are needed to address these interconnected concerns. Similar syndemic conditions may affect vulnerable women worldwide in high-risk situations like poverty, domestic abuse, sex work and limited access to healthcare and education. The combined effects of drug abuse, violence and STIs among women in prison are probably indicative of more significant global trends that impact at-risk women. This necessitates implementing public health programmes that integrate services from multiple social and health sectors. Intervening with women at risk while they are incarcerated can enhance rehabilitation services and perhaps moderate recidivism rates and/or improve long-term health outcomes for these women in prison or on release.25

### Limitation

It is essential to consider this study’s limitations while interpreting the findings. The study’s cross-sectional nature limits the ability to establish causal links between the observed latent profiles and STI symptoms. Furthermore, the dependence on self-reported data regarding substance use, violence and STI symptoms may result in reporting bias, which could result in the underestimation or overestimation of these behaviours. The sample exclusively consists of incarcerated women in Peru, which may restrict the applicability of the results to different incarcerated populations or contexts. Furthermore, a mild dependency between violent elements, even after accounting for relevant discrepancies, implies the possibility of residual confounding that may impact the strength of the results. To overcome these constraints, future research should use longitudinal designs, validate self-reported data using objective measurements and investigate these associations in various demographics and circumstances.

## Conclusions

This study presents compelling evidence of the association between a syndemic profile of substance use and violence and a higher prevalence of symptoms related to STIs among incarcerated women in Peru. Given the resource-limited setting of prison healthcare systems, these findings suggest a potentially cost-effective syndromic management approach for STI prevention and treatment.26 Routine diagnostic screening for STIs may not be feasible in such settings, but brief survey-based screening methods, leveraging self-reported STI symptoms alongside psychosocial factors such as violence and substance use, could help identify high-risk individuals for prioritised care.

The broader public health implication is that providing targeted treatment for incarcerated women offers long-term societal benefits. In minimum-security prisons, where individuals are released within 5 years, addressing their reproductive health needs has the potential to improve their quality of life and facilitate their reintegration as healthy mothers, productive citizens and contributors to society.27–29 Treating these women while they are incarcerated reduces immediate health risks and enhances their economic productivity on release, making it a potentially cost-effective strategy with significant social and economic returns. Future research should explore the implementation and evaluation of integrated care models that address intersecting needs to improve health outcomes for incarcerated women and reduce health inequities in vulnerable populations.

These findings emphasise the importance of adopting a syndemic approach to STI prevention and treatment in this vulnerable population and emphasise the necessity of holistic interventions that address the interconnectedness of substance use, violence and sexual health. Previously proven interventions, such as trauma-informed care and substance abuse treatment programmes, could be implemented during their period of incarceration to address these concerns. Policy reforms incorporating structural interventions, psychological programmes and drug treatment could effectively mitigate the adverse effects of incarceration and involvement in the criminal justice system on individuals and communities that are vulnerable to HIV and other STIs.30

To enhance the health and well-being of incarcerated women and other vulnerable populations worldwide, it is crucial to acknowledge and tackle the social and behavioural variables that contribute to STI risk. The study also highlights the need for further research to explore the mechanisms underlying these associations and to evaluate the effectiveness of integrated intervention programmes. Comprehensive, integrated care approaches are necessary to reduce the prevalence of substance use, mitigate violence and provide effective STI prevention and treatment. Future research should continue to investigate the interplay between these factors to refine intervention methods and improve health outcomes for vulnerable populations. By addressing these complex needs, meaningful strides can be made in improving health outcomes and reducing disparities for some of the most marginalised populations.

### Abstract translation

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.[[sextrans-2024-056371supp002.pdf]](pending:yes)

## Data availability statement

Data are available upon reasonable request. The data presented in this study are available upon request from the corresponding author. The data are not publicly available due to privacy concerns.

## Ethics statements

### Patient consent for publication

Consent obtained directly from patient(s)

### Ethics approval

This study involves human participants and was approved by the Health Sciences Institutional Review Board of FIU (approval code: IRB-16-0402; approval date: 17 October 2016); the Comite Institucional de Bioetica de la Asociacion Civil Impacta Salud y Educación (approval code: N 0136-2014-CE; approval date: 18 August 2014); the Instituto Nacional Penitenciario (approval code: INPE/18.05; approval date: 30 April 2015); the Office for Human Research Protections (IRB 00006865; approval date: 16 June 2015); and the Human Investigation Committee, Yale University (approval code: HIC 1410014783; approval date: 6 May 2015). This study was conducted according to the guidelines of the Declaration of Helsinki. Participants gave informed consent to participate in the study before taking part.

## Acknowledgments

We are grateful to all those with whom we have enjoyed working on this and other related projects. Each of our team members has provided extensive professional guidance during the study. The team acknowledges Celia Floriano Orozco, Virginia Huancare and Luis Riega Viru from Instituto Nacional Penitenciario del Perú, Lima, Perú, for their support and guidance throughout our research.

## Footnotes

*   Handling editor David Regan

*   Contributors Conceptualisation: EC, AM-L, FLA, MS. Data curation: EC, RT, EH. Formal analysis: EC, RT. Interpretation: EC, RT, AM-L, JDS, TD. Methodology: EC, RT, EH, SA, ACB, AM-L, JDS, SRL, FLA, MS, TD. Funding acquisition: EC. Supervision: EC. Resources: EC, ACB, AM-L, JDS, SRL, FLA, MS, TD. Validation: AM-L, JDS, SRL, FLA, MS, TD. Writing—original draft: EC, EH, SA. Writing—review and editing: all authors. Guarantor: EC

*   Funding The project was supported by the National Institutes of Health and awards NIDA (K99/R00DA046311), LRP (L30AA027051) and FIC (D43TW011324).

*   Disclaimer The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institutes of Health.

*   Competing interests None declared.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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