Correctional facilities or prisons form part of the criminal justice system and it is estimated that over 9 million people are in penal institutions worldwide. Overcrowding in prisons remains a concern in both developed and developing countries, and is a key causative factor for a myriad of other problems which ultimately turn these custodial settings into fertile breeding grounds for infectious diseases such as AIDS, hepatitis, syphilis, gonorrhoea and tuberculosis. Compared to the general population, prisoners worldwide continue to demonstrate a significantly higher prevalence of bloodborne and sexually transmitted infections [1
]. Prison officers not engaged in healthcare delivery (PONEIHD) [category II workers] are recognized to be at increased risk for these infections because of the high prevalence of these infections among inmates and their close interaction with the inmates in the performance of their job [32
]. Knowledge of the correlates of bloodborne viral infections and sexually transmitted diseases (STDs) in different parts of the world, and particularly in Africa in the face of limited resources, is important for the planning of preventive measures and the development of vaccination programmes. Furthermore, the comparison of the prevalence among prison inmates, prison officers and the general population in the same geographical area is important to provide a basis for action, and changes in public health policy, education and clinical practice. Numerous studies have estimated the occupational risk of exposure and infection with bloodborne pathogens for hospital-based and correctional healthcare workers (category I workers) [9
], but similar data are sparse for PONEIHD. Systematic surveillance of HIV, HBV, HCV and syphilis in prison inmates and officers in Ghana is completely absent, and there is no formal program for institutionalized implementation of standard infection control practices, bloodborne infectious disease risk reduction recommendations, mandatory screening and HBV immunization upon employment and treatment for both prison inmates and officers in the Ghana Prison Service.
This study found higher overall seroprevalence rates of HIV (5.9%), HBV (25.5%) and syphilis (16.5%) in Ghanaian prisoners, as compared to the seroprevalence of these infections previously reported in the general public in Ghana, mainly healthy blood donors and pregnant women [35
]. The present study supports previous reports that prisoners represent a high-risk group for bloodborne diseases and STDs [1
]. The overall seroprevalence of HIV, HBV and HCV [22
] among Ghanaian prisoners (5.9%, 25.5% and 18.7%, respectively) is higher than the results of a similar study in incarcerated populations in the United Kingdom (0.4%, 8.0% and 7.0%, respectively) [25
]. Additionally, the overall seroprevalence of HIV, HBV, syphilis and HCV [22
] among Ghanaian prisoners (5.9%, 25.5%, 16.5% and 18.7%, respectively) is higher than the results of a similar study in incarcerated populations in Brazil (3.2%, 17.5%, 7.4% and 6.3%, respectively) [28
]. Finally, the overall seroprevalence of HBV and syphilis among Ghanaian prisoners (25.5% and 16.5%, respectively) is higher than the results of a similar study in incarcerated populations in the United States of America (25.2% and 0.6%, respectively) [45
], however that of HIV and HCV [22
] in Ghanaian prisoners (5.9% and 18.7%, respectively) is lower than that in prisoners in the United States of America (6.6% and 29.7%, respectively) [45
]. From the comparison above, the higher prevalence among Ghanaian prisoners compared to prisoners in the United States of America [45
], the United Kingdom [25
] and Brazil [28
] most probably reflects the current absence of any harm reduction interventions in Ghanaian prisons whilst variable extent of implementation of such interventions are currently in place in prisons in the United States of America, the United Kingdom and Brazil. However, the higher prevalence of HIV and HCV in prisoners in the United States of America compared to Ghanaian prisoners (in whom no harm reduction interventions have yet been implemented) most probably reflects a persistently higher prevalence of intravenous drug use within and without the prisons in the United States of America compared to Ghana, despite the implementation of harm reduction interventions within most prisons in the United States of America.
This study found higher overall seroprevalence rates of HIV (4.9%), HBV (11.7%), HCV (18.7%) and syphilis (7.9%) in Ghanaian PONEIHD, as compared to the seroprevalence of these infections previously reported in the general public in Ghana, mainly healthy blood donors and pregnant women [35
]. However, the seroprevalence in the prison officers is comparable but generally lower to the similarly high seroprevalence observed in prisoners in this study and previously reported in prisoners in Ghana (5.9%, 25.5%, 16.5% and 18.7%, respectively) [19
], though the seroprevalence of HCV was even higher in the prison officers than the prisoners. Our observed overall HBsAg carrier rate of 11.7% among Ghanaian PONEIHD is higher than the results of a similar seroepidemiology study in PONEIHD in Italy (6.6%), which reported a comparable HBsAg carrier rate of 6.7% in prisoners in Italy [20
]. However, our observed overall HBsAg carrier rate of 11.7% among Ghanaian PONEIHD is lower than that of a similar study in PONEIHD in Greece (20.0%), which was higher than the HBsAg carrier rate of 13.3% in prisoners in Greece [21
]. Our observed HCV seroprevalence of 18.7% in Ghanaian PONEIHD is much higher than that reported in PONEIHD in Greece (5.0%), which was lower than the HCV seroprevalence of 15.5% in prisoners in Greece [21
]. A more recent study among correctional healthcare workers or prison officers employed in healthcare delivery in three states in the United States of America reported no evidence of chronic HBV infection (ie, 0% HBsAg carrier rate) and 2% HCV seroprevalence [10
], which was much lower that that herein reported for PONEIHD in Ghana and that previously reported for prison officers in Italy [20
] and Greece [21
]. From the comparison above, the higher seroprevalence of especially HCV among Ghanaian prison officers compared to prison officers in the United States of America [10
], Italy [20
] and Greece [21
] most probably reflects the current absence of any institutionalized infection control measures and harm reduction interventions in Ghanaian prisons whilst variable extent of implementation of such interventions are currently in place in prisons in the United States of America, Italy and Greece.
The seroprevalence rates of HIV, HBV and syphilis infections were significantly higher in inmates aged 17–46 (which spans the generally accepted sexually-active age group of 15–45 years), unmarried inmates, illiterate inmates, female inmates, inmates incarcerated for longer than the median time served of 36 months, inmates reporting previous histories of homosexuality, of IDU, of sharing drug paraphernalia, or participating in paid sex, and of STD. These observed risk factors for all three infections in Ghanaian prisoners are generally considered as indicators of either intravenous drug use (history of IDU and sharing drug paraphernalia, and prolonged incarceration), high-risk sexual behaviour (sexually-active age group, unmarried, homosexual orientation, participation in paid sex and history of STD), or lower socioeconomic status (illiterate and female gender). The seroprevalence rates of HIV, HBV, HCV and syphilis infections were significantly higher in prison officers aged 25–46 (which spans the generally accepted sexually-active age group of 15–45 years), unmarried prison officers, female prison officers, prison officers employed for longer than the median duration of 10 years, and reporting a previous history of STD. These observed risk factors for all four infections in Ghanaian prison officers are related to the duration of exposure to work in the prison environment, high-risk sexual behaviour (sexually-active age group, unmarried, and history of STD), or lower socioeconomic status (female gender). Our observed significant associations between HIV, HBV, HCV and syphilis seropositivity status among the prison inmates and officers in Ghana suggests that the transmission of all four infections may be linked and are related to the same identified risk factors above.
The herein reported seroprevalence rates of HIV, HBV, HCV and syphilis are more representative of the Ghanaian prison population, because of the much larger sample size, than that previously reported [19
]. The explanations for the varied seroprevalence of the four infections between the eight sites studied, and the variation in level of participation between the eight study sites are not obvious from this study. The significantly higher prevalence of these bloodborne and sexually transmitted infections in female prison inmates and officers compared to their male counterparts in Ghana is not unexpected, since similar gender disparity has been reported in prisoners and minority women in the southern United States of America [46
] driven by similar predisposing sexual and socioeconomic risk factors as we have described above in prisons in Ghana. Addtionally, women are also more likely to engage in commercial sex work (CSW), a high-risk sexual behaviour that correlate with the prevalence of syphilis and other STDs [29
]. Our observed gender disparity in the risk of these infections in the Ghanaian prison system most probably also reflects the general lower socioeconomic status of women worldwide (but especially in developing countries like Ghana), and emphasizes the specific needs of women in the implementation of efforts at reducing the risk for bloodborne and sexually transmitted infections.
The results of this study suggest that PONEIHD in Ghana may have exposure rates to bloodborne infections that are comparable to those in published reports regarding hospital-based health care workers (HCWs) [category I exposure risk rather than category II exposure risk) [9
]. This suggested level of exposure is surprising, since PONEIHD in Ghana do not administer any acute healthcare to prisoners compared to that done by HCWs in acute care hospitals. Apart from occupational exposure, the exchange of sexual favours between prison officers and inmates, which is not unheard of, may be another mitigating factor in the comparably high seroprevalence of these bloodborne and sexually transmitted infections in Ghanaian prison inmates and officers. A concerning finding was that the prevalence of HCV infection in the prison officers was even higher than that in prisoners in this study and previously reported in prisoners in Ghana [19
]. Therefore, the present study substantiates the concern that PONEIHD may be at significantly increased risk of bloodborne infections, especially HCV, because of the particularly high prevalence of HCV among prisoners worldwide [1
]. The observation of the comparably higher prevalence of antibodies to these infections among the prison officers and prisoners, compared to the general Ghanaian population, is strong presumptive evidence of intra-prison transmission between prisoners and prison officers. The cross-sectional scope of the current study did not allow us to determine whether the prison inmates and officers acquired the diseases while within or outside of the prison. However, growing evidence also suggests that in general, prisoners are more sexually active in the community than the general population, reporting a higher number of partners and lower use of condoms [28
]. Most prisoners have the high-risk behaviours for the transmission of these infections. Besides illicit drug use, unsafe sex and homosexuality, prisoners frequently tattoo their skins out of boredom, and in the process share needles and ink. These high-risk behaviours place prisoners at increased risk of infection with blood-borne viruses in comparison to the rest of the population [22
The cross-sectional study design, reliance on self-reporting, sociocultural and religious beliefs, and job security/victimization concerns of the study participants (despite all our assurances of confidentiality during the explanation of the purpose of the study) may be possible biases and limitations of the study. In spite of these possible biases or limitations, this study provides important information previously unavailable on prisoners and PONEIHD in Ghana and can serve as a platform on which other studies can build. This study would contribute to efforts to respond to the important healthcare needs of these vulnerable individuals in Ghana. The results of the study reveal worrying trends for officials of the Ghana Prisons Service and the Ministries of Interior and Health, Accra, Ghana, who are charged with the management of bloodborne and sexually transmitted infections in the country. The implications of these findings for HIV, HBV, HCV and syphilis public health education are obvious. The results reported herein have significant implications for penal and public health officials, and suggest the urgent need for the introduction of policies to prevent the transmission of these infections in the prison environment. Even with resource limitations in Africa, effective partnerships between the prison officials, governmental, non-governmental and donor organizations would make headway in addressing issues of prison health as public health issues in Africa. The development and implementation of effective prison health initiatives providing counseling, health education, confidential voluntary testing, care pathways, strategies for interrupting transmission as well as harm reduction in Ghana is urgent and long overdue. Such initiatives would ultimately benefit the inmates, the correctional officers, families, communities and the general Ghanaian population.
The main focus of these risk reduction efforts should be on providing access to the prison environment to skilled infection control practitioners to create a strong safety climate that is supportive of safe work practices, the use of safety equipments and other engineering controls, and urgent implementation and compliance with vaccine recommendations, especially for HBV. This has to be a nationwide effort, with support for infection control coming from the highest possible political and administrative level. A clear, thoughtful, well-planned, and carefully structured risk reduction approach that targets specific corrections-related barriers to infection control is urgently needed for prison officers in Ghana. Additionally, postexposure management protocols should be in place, and prison officers should be well informed about the procedures they should follow in the event of percutaneous injuries whilst on the job. This training should be documented, and employee vaccination records should be well maintained. We also recommend that all prison officers must be screened at the time of employment to determine their status with regards to these bloodborne and sexually transmitted infections, and HBV vaccination offered to seronegative new hires. Although, the prison inmates and officers participating in our study cannot be considered representative of all the prison inmates and officers in Ghana, the results reported herein have significant implications for penal and public health officials, suggesting the importance of introducing policies to prevent transmission of these infections within the prison system. These policies must include testing programmes in prisons, which should be seen as an opportunity to improve the health status of the infected prison inmates and officers, and prevent further transmission of the infectious agents, within and without the prisons. Finally, we recommend that the prison population (both prison officers and prisoners) should be included in the routine national disease surveillance programs of the Ministry of Health so as to provide a more representative picture of the epidemiology of bloodborne and sexually transmitted infections in Ghana.
The policy of the Ghana Prison Service is to send prisoners to any prison in Ghana where there is a vacancy at the time of committal, and not necessarily to the prison nearest to the site of crime or the site of trial. Additionally, the policy of the Ghana Prison Service is to post prison officers based on rank, expertise and qualification to any prison in Ghana where there is a vacancy. Hence, the absence of these two regional central prisons is not likely to impact the representativeness of our sample. However, the sociocultural and religious beliefs, and security concerns of the study participants may be additional limitations of the study, despite all our assurances of confidentiality during the explanation of the purpose of the study. As a result, some inmates may not have responded correctly to the parts of the questionnaire relating to sexual orientation, drug use and history of STD. In spite of these limitations, the study results provide important data on the correlates of HIV, HBV and syphilis infections among people sent to jail, and may contribute to efforts to respond to the important healthcare needs of these vulnerable individuals in Ghana. These policy strategies must include increasing prisoner and correctional staff education about the prevention of these infections, testing for and treatment of infected inmates, education in tattoo application and the provision of professional tattooing services, the provision of bleach, and the provision of clean injecting equipment [54
]. The implementation of these harm reduction programme in prisoners in Ghana should be seen as an opportunity to improve the health status of the infected prison inmates and to prevent further transmission of these infections, within and without the prisons. As a rule, there are inadequate medical facilities and staff in the prisons in Ghana, and access to appropriate care outside the Ghana prison system is very difficult for the inmates. Although the World Health Organization's (WHO) guidelines for HIV/AIDS in prisons stipulate that all inmates have a right to equitable health care and that national AIDS programmes should be applied in jails, this is rarely the case in many African countries, including Ghana. Ultimately, this approach benefits not only prisoners but also prison staff and the public, and does not entail lessening of the safety and security of prisons. Most inmates eventually get released and those infected represent a serious risk to their families and communities as they are reservoirs for further spread in the general population. Further studies are underway to determine the modes of transmission, and to institute interventional measures.