In addition, there is the social stigma related to both STDs and HIV. MSF hosts information sessions to both inmates and prison officers that raises awareness of sexually related issues. However the challenge is the negative connotations within the prison population associated with a simple visit to an MSF informational session. An inmate's fear of visiting the clinic is the possibility of being ostracized and shunned within the penitentiary's social structure.

A sentence to a prison term to Lima's Lurigancho Penitentiary represents many risks - including the possibility of contracting HIV / AIDS. In this particular prison, inmates are seven times more likely to acquire an infection of HIV / AIDS than on the street. In Peru there are places, such as prison, where the HIV virus is all but walking freely. Since 2000, the aim of Médecins Sans Frontières (MSF) in Lurigancho Penitentiary has been to combat the spread of all sexually transmitted diseases (STDs), while treating other AIDS-related illnesses.

However, in one of the most overpopulated prisons in Latin America, where overpopulation has reached a staggering 7,016 men occupying a space allotted for only 1,800, MSF activities would fail if not adapted to the prison's unique infrastructure. Nothing is easy in the prison, as the distribution of the limited number of condoms to the prison population can be extremely challenging. "In jail you pay for everything and a condom has an economical value that can be scalped", explained Katelijn Deknoper, MSF's Project Coordinator for Lurigancho Penitentiary since 2001.

On the third floor of the hospital, where the MSF doctors work with Lurigancho Penitentiary's Health Department staff, pills are no longer distributed in the cells. Instead the inmates are asked to visit the consultation clinic. Unless directly monitored, the pills are quickly converted into currency. Even in the worst medical scenarios, inmates will continue to sell their required medications for actual currency.

Gonzalo Chavez, the MSF epidemiologist of four months, said: "What is good is to be close to the inmates and listen to them; We learn to understand them and try to prevent these types of abuses within their population". However this is easier said than done. MSF's long term objective of complete intervention with the prison population often seems unattainable.

"It is almost impossible to change the prison environment," said Ketelijn Deknoper. "When security is the main priority for the prison authorities, health is not one of the daily concerns of the prisoners and risk situations like drugs, alcohol or lack of condoms are constant". The majority of prisoners go for an MSF consultation only when they are suffering from dire health conditions. In Lurigancho Penitentiary's medical facilities, MSF treats 65 cases of HIV/AIDS. However, the prison's seroprevalence index of 2.6 indicates that there are at least 180 possible carriers of the HIV/AIDS in the facility.

"The problem is that in most of the cases the inmates are not conscious of the high risk they are confronted with," said Deknoper. "We are talking about people without medical coverage - even outside the prison - so they are more susceptible to illnesses and they are not thinking about taking care of themselves". In addition, there is the social stigma related to both STDs and HIV.

MSF hosts information sessions to both inmates and prison officers that raises awareness of sexually related issues. However the challenge is the negative connotations within the prison population associated with a simple visit to an MSF informational session. An inmate's fear of visiting the clinic is the possibility of being ostracized and shunned within the penitentiary's social structure.

"Inmates who act as liasons between MSF and the prison population can visit the community clinic without fear of being labelled as having an illness," explained Dr. Chavez. "We support them and they inform us what is going on inside the cell blocks".

'Jail Girls' are a high risk group

Another initiative of MSF is to focus on high risk groups within Lurigancho Penitentiary, such as the prison's sex workers. The prevalence of HIV is extremely high among the tranvestite's of the "Virgen de la Puerta", known also as "The Jail Girls". MSF's task within this particular prison popullation is to strengthen the group's self-esteem and to assist in prevention while providing support therapy.

New intervention

The MSF team is now preparing further intervention with another high risk group - new inmates. Project Coordinator Katelijh Deknoper is convinced that "it is easier to influence the newcomers to the prison than the repeat offenders when suggesting a general medical evaluation that also tests for STD's and HIV". The inmates and MSF have also prepared an informational leaflet for the new arrivals that could possibly help in prevention.

The leaflet is unique because it incorporates the direct "street" language that uses slang, warning inmates about the health risks of having unprotected sex. In its initiatives at Lurigancho Penitentiary, MSF, like the name of the leaflet, is indeed seeking "La Firme (The Truth) about STD's".