HIV and HBV Infection, Knowledge and Risk Behaviour in Ghanaian Prisons Edward Adiibokah1, Emmanuel T. Larbi1, Francis S. Hagbe 3, Stephen A. Addo 2 , Angela EL- Adas1 1Ghana AIDS Commission, Ghana , 2 National AIDS Control Program, 3Ghana,Ghana Prisons Service

Background HIV and HBV infections are more common among prison inmates than the general population-6 to 50 times higher than the general adult population (UNODC, 2007). Previous studies in Ghanaian prisons have reported HIV prevalence of 19.2% (Adjei et al.,2006 ) and 5.9% (Adjei et al.,2008) Objectives Assess the situation of HIV, HBV and other key illnesses among prison inmates in Ghana Identify factors that contribute to prison inmates being infected with HIV and HBV Make recommendations to guide the development of HIV/AIDS and health programmes for Ghanaian prisons Source: National AIDS/STI Control Programme

Methods Cross-sectional Integrated Bio-Behavioural Surveillance Survey conducted from June to August 2012 Behavioural survey - inmates’ knowledge, attitudes, behaviours (before and during imprisonment ) and prison environment factors Biomedical component : test for - HIV, HBV, Malaria, Diabetes, Hypertension and underweight/overweight Inclusion criteria All adult prisoners : on remand, awaiting trial and convicted and sentenced , all forms of prison sentences & categories of prisons Exclusion criteria Prisoners considered too great a risk for harm to themselves or interviewers Not competent (sick or intellectually immature) Could not speak English or any other Ghanaian language

Method- Sampling Procedure 2,443 prisoners were involved in the study, comprising 205 female and 2,238 male inmates Male Prisoners : first stratified by type of prison, 12 out of 34 eligible prison stations were selected randomly , inmates selected systematically using a list Female Prisoners : all inmates were involved due to their limited number Ethical considerations : Noguchi IRB and the Ghana Health Service Ethical Review Committee Data analysis : Descriptive statistics , bivariate & multiple logistic regression using SPSS version 18.0. A p-value of 0.05 was used to determine statistical significance

Results – socio-demographic s & Prison Environment Mean age - male inmates 34.1, years (SD =11.8), Females inmates 37.6 years (SD=13.8) Over 70% were less than 40 years, with 3% being less than 20 years About 18% had never been to school Only 4% of male inmates and 6.8% of females have had tertiary education Characteristic Male (%) Female (%) Total (%) Type of sentence  On Remand 14.3 29.8 15.6 Convicted 85.7 70.2 84.4 Type of Prison  Maximum Security 2.2 0.0 2.0 Medium security 29.1 48.3 30.7 Central prison 39.6 45.9 40.2 Local prison 14.5 5.9 13.8 Camp prison 13.3 Length of stay in prison ≤1 year 31.1 42.0 32.0 1-5 years 54.1 49.2 53.7 ≥6 years 14.8 8.8 Ever Imprisoned Yes 6.7 6.3 No 93.3 98.0 93.7

Results – Knowledge about HIV & AIDS-related risk behaviours Awareness about HIV/AIDS is almost universal (99%) among Ghanaian prison inmates Overwhelming majority (96% male vs. 97% females) reports that HIV can be prevented by having only one uninfected sexual partner About 9 in 10 inmates know that HIV can be prevented by using condoms all the time

Results-Common STI symptoms inmates reported as having suffered before incarceration and during prison

Results - HIV risk behaviours Blood-related HIV risk behaviours Sharing razor blades in prison - 29% of males and 9% females Ever tattooed before imprisonment - 17% males and 19% females Ever tattooed within prison -1.4% males and 1.5% females High-risk sexual behaviour Casual sex 12 months before imprisonment - 58% males and 30% of female prisoners (more than one partner 49% ) Sex with CSWs- 23% of males and 2.5% of female (inconsistent condom 46% use) Anal sex with other inmates was 0.4% Injecting Drug use Ever used drugs before incarceration - 55% male & 20% female (72% wee; 55% alcohol) Ever injected drugs in prison - 3 (0.1%) 1% of inmates reported they ever injected drugs prior to imprisonment No report of sex with IDUs in prison

Summary of biomedical test results by sex Overall (%) Male (%) Female (%) HIV 2.3 1.5 11.8 HBV 12.8 13.3 7.8 Malaria 5.5 5.7 3.4 Diabetes 0.6 0.5 1.0 Blood Pressure (S+D) 26.3 25.5 35.6 Systolic BP 19.2 18.6 25.4 Diastolic BP 19.8 18.9 30.2 Underweight (Low BMI) 3.5 3.6 2.4 Overweight (High BMI) 24.0 21.2 53.7

HBV status by behavioural characteristics Total % HIV positive P-value Access to blades /razors for shaving Yes 2366 12.8 p =0.939 No 72 12.5 Sharing of blades /razors with other inmates 664 11.6 p =0.267 1761 13.3 Ever been tattooed outside prison 406 13.5 p =0.644 2015 12.7 Ever been tattooed within prison 34 2.9 p =0.115 2389 12.9 Sex with CSW before imprisonment 515 13.4 p =0.623 1923 12.6 Ever had casual sex before imprisonment 1352 p =0.719 1087 13.1 TOTAL 2442

Discussions & Recommendations While HIV prevalence among males was un-expectantly low, that of females was several fold that of the general population Confirming the vulnerabilities of female prison inmates. HBV prevalence among both males and females was high. Risky behaviours (sexual/drug use/sharing implements) appear to be rare in prisons with no statistically significant relationship between these risky behaviour in prison and HIV and HBV positive status. Given that inmates in prison are less likely to get infected, new entrants should be offered voluntary counseling and testing before admission into the prisons

Under the Office of the President THANK YOU Under the Office of the President P. O Box CT 5169 Cantonments, Accra – Ghana Tel: +233 302 919260/ +233 302 919259 Fax: + 233 302 218 279 www.ghanaids.gov.gh info@ghanaids.gov.gh