Introduction: Prisons are human incubators in which some people with different behaviors live together, and after they gain freedom, many of these prisoners will come back to the community. The aim of this study was to evaluate the risk factors for hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections in Iranian prisoners.
Methods: This case-control study is done on 1431 Iranian prisoners who were arrested because of drug-related offenses. After getting information and performing the tests for HBV, HCV, and HIV infection, the odds ratio (OR) was calculated for every risk factor.
Results: A total of 1431 prisoners was studied, out of them, 1153 had a history of addiction to a narcotic drug, and 28% of them were intravenous drug users (IDUs). This study revealed that tattoo is the most important risk factor for HBV infection in Iranian prisoners (OR, 1.85; 95% confidence interval [CI], 1.00-3.43). It also revealed that the most important risk factor for HCV and HIV infections is IDU (OR, 14.73; 95% CI, 11.13-19.50; and OR, 4.48; 95% CI, 2.89-6.93, respectively).
Conclusions: It seems that there are many various risk factors in Iranian prisons for blood-borne infections (HBV, HCV, and HIV), and it should be emphasized that in Iranian prisons, IDU and sharing needle, razor, and tattooing equipments are the major risk factors for these infections, and harm reduction programs should be focused on these problems in Iran.
*Department of Internal Medicine, Jahrom Faculty of Medicine, Jahrom; and †Department of Infectious Diseases and Infectious Research Center, Esfahan University of Medical Science, Esfahan, Iran.
Address correspondence and reprint requests to Morteza Pourahmad, MD, Jahrom Faculty of Medicine, Jahrom, Iran. E-mail: firstname.lastname@example.org.
Today, along with tuberculosis and malaria, infections by hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are the main problems in the world.
Available evidences reveal that the number of chronic carriers of HBV is estimated to be more than 400 million worldwide,1 and the World Health Organization (WHO) estimates that one third of the people in the world has been infected with HBV.
On the other hand, we know that 35% of Iranian people have had contact with HBV, and 3% of them are chronic carriers for HBV; it is revealed that Iran is a region of moderate endemicity for HBV in the world. It should be stated that the prevalence of hepatitis B surface antigen (HBsAg) positivity is reported up to 25% in a few prisons among the intravenous drug abusers (IVDAs).2
The HCV is one of the leading causes of infectious hepatitis worldwide,3 and the WHO estimates a worldwide prevalence of 3% for that.4 It estimated that more than 170 million persons are HCV infected worldwide,5 and its transmission is mainly by blood products and sharing of intravenous paraphernalia during illicit drug use.3
The data on HCV prevalence in Iran are different; in some reports, HCV prevalence in Iranian blood donors is about 0.04%, and in 2002, the WHO reported that prevalence of HCV in Iran is about 1% to 2.5%.6 On the other hand, according to some other published data, the prevalence of HCV infection in Iran is 0.59% to 0.8%.7
Moreover, HCV infection among Iranian prisoners is high, despite low HCV seroprevalence in the general population.8
According to some reports, up to 40% of Iranian prisoners who are intravenous drug users (IDUs or IVDAs) are positive for anti-HCV antibody (Ab).9 This shows the worse condition in prisons and/or IVDAs.
Human Immunodeficiency Virus Infection/Acquired Immunodeficiency Syndrome
At the end of 2002, the joint United Nations Program on HIV/Acquired Immunodeficiency Syndrome (AIDS) estimated that 42 million adults and children were living with HIV/AIDS worldwide.1010
The advance of AIDS in the Middle East and North Africa has continued with the latest estimates, showing that 67,000 people became HIV positive in 2005. It seems that approximately 510,000 people are living with HIV in the region, and about 58,000 adults and children died of AIDS-related illnesses in 2005.11 Available evidences reveal that the main mode of HIV transmission in this region is unprotected sexual contact, although injecting drug use is an increasingly important factor and is the predominant mode of infection in Iran and Libya.11 They say that HIV is circulating widely among drug injectors, of whom there were an estimated 200,000 in 2003 and looks set to spread further.11 On the other hand, they estimated that HIV/AIDS cases in Iran are about 30,000 until 2004, although on the latest report, all known cases of HIV/AIDS in Iran are about 13,357, and they estimate that 64% (8650) of them are IVDAs and may take disease via this route.12
As we know, there are many different risk factors and routes for transmitting HBV, HCV, and HIV infections, and it should be noted that in every community, the routes and risk factors for these infections may be different from those in another community, so it is better to evaluate these conditions in every community.
Our knowledge about the most important routes and risk factors for HBV, HCV, and HIV transmission can help us to program for better prevention of these viral diseases. On the other part, it should imply that prisons are important incubators, where inmates are held for unconscionably long periods in abysmal conditions (crowding, poor nutrition, dismal medical care, and exposure to homosexual activity). So, in addition to the risk of infectious disease spread in the prisons, when prisoners are released into the community, they contribute to the further spread of diseases.1313
The control of infections in the prisons can help in their control in the community.
Although we know that these infections may occur before and/or during imprisonment, we conducted this study to evaluate the risk factors for HBV, HCV, and HIV in Iranian prisoners that can help programming control of these infections in the prisons and the community.
MATERIALS AND METHODS
This is a case-control study, which is done in 4 prisons in 3 provinces in Iran (Esfahan, Chaharmahal Bakhtiary, and Lorestan) in 2003.
We enrolled 1431 male prisoners, who have been imprisoned for various drug-related offenses (purchase or sale and consumption). We chose these prisoners because the chance of infection with hepatitis virus and HIV is high in this group. It should be implied that the prisoners in these 4 prisons were from all over the country, and they could be representative of the prisoners of the whole country, and because the behaviors of the prisoners are the same, we can use the results for practical programming for all the same prisoners all over the country.
This study was evaluated and approved by the ethical committee of Esfahan Medical University.
For better communication with prisoners, we got aid from some prison staff who were reliable for prisoners (and we also could rely on them for giving the right information). These individuals filled the questionnaires by face-to-face interview with the prisoners.
After getting a code number to every one of the prisoners, information was gathered regarding their demographic characteristics and important risk factors for HBV, HCV, and HIV infections.
All data were kept confidential. A blood sample was obtained by venipuncture, and serum was separated and stored at −20°C. The HBsAg, HCV, and HIV tests were performed on all blood samples by Italian Diasorin enzyme-linked immunosorbent assay (ELISA) kits and Stat Fax system. We repeated the ELISA test on all the samples that were positive the first time (double ELISA).
For HCV and HIV tests that have been positive in double ELISA, we came back to the prisons, and after recognizing the prisoners by their special codes, we got blood samples from them again, and Western blot test, for confirmation, is performed on these samples. The prisoners were informed regarding their hepatitis/HIV results. And if their tests were positive, they were referred to the prison health system for better management.
After collecting the information, we categorized them by SPSS software (version 12) and relative risk (odds ratio [OR]) with 95% confidence interval (CI), calculated for each risk factor for HBsAg, HCV Ab, and HIV Ab positivity.
In this study, 1431 prisoners were enrolled. They settled in 4 prisons in 3 provinces in Iran, and all of them were men.
Imprisonment duration was between 1 and 10 years in these prisons, and prisoners were aged 25 to 60 years.
From 1431 studied prisoners, 1153 persons (80%) had a history of addiction to a narcotic drug, and 401 (28%) of them were IVDAs. From 401 IVDAs aforementioned, 236 persons (58.8% of IVDAs and 16.5% of total prisoners) were share needle users.
On the other hand, from 1431 studied prisoners, 399 persons (27.8%) had a history of illegal sex, and 113 of them (28.3% of illegal sex users and 7.8% of total) had a history of homosexuality (the meaning of illegal sexual contact was homosexuality and/or sex with another other than wife or husband).
In this study, 46 prisoners (3%) were HBsAg positive, 497 prisoners (34.7%) were HCV Ab positive, 92 prisoners (6.4%) were HIV Ab positive, and 8 prisoners (0.5%) had triple infections. We evaluated the risk factors in these prisoners too(Tables 1-4).
Intravenous Drug Abusing
Intravenous drug abusing is a very important risk factor for HBV, HCV, and HIV that was revealed in many researches. In a study in Denmark, 43% of prisoners were IVDAs, and 70% of them had used shared injecting equipments.14 These numbers were 24% and 75%, respectively, in England,15 and in our study were 28% and 58.8%, respectively. In a study that was conducted on drug users who visited 3 public drug treatment centers in Tehran, it revealed that a history of shared injection inside prison (OR, 12.37) was the main factor associated with HIV infection among male injectors, with an HIV prevalence of 15.2%.16
In a study in Greece, on the other hand, these numbers had been more. In that study, 68.9% prisoners had been IVDAs, and 92% of them had shared injecting equipments.17
In a similar study in Rhode Island prisons, there were associations between HBV, HCV, and HIV infections and intravenous drug using (OR, 7.9 for HBV, 32.4 for HCV, and 10.1 for HIV).18
Many other studies also emphasize that intravenous drug abusing is the major risk factor for these infections.3,19-21
In fact, in IVDAs, needle sharing is responsible for transmission of the infections, but in our study, its risk is just a little less than intravenous drug abusing itself (as a risk factor).
This difference may be caused by denying of this act by some of the IVDAs. On the other hand, it should be noted that there are some other risk factors (such as razor sharing, tattoo, etc) for transmitting these infections that may interfere with this risk factor.
However, some countries try to control this risk factor in prisons and have conducted prison-based needle exchange programs. To assess these programs, a few studies have been conducted, and they revealed that the provision of syringes for IDUs in appropriate prison setting may contribute to a substantial reduction of syringe sharing. Such programs are feasible and do provide benefit in the reduction of risk behavior and the transmission of blood-borne infection without any unintended negative consequences.22-26
On the other hand, some of these studies believe that the Ministry of Justice should consider improved and additional harm reduction strategies. These include increased availability of bleach and condoms and the introduction of methadone treatment and syringe exchange in prison.27
The tattooing procedure, often carried out in prisons, and use of unsterile equipments are possible ways of HBV, HCV, and HIV transmission.
Our study revealed that the most important risk factor for HBV transmission is tattooing, and its importance for HIV transmission is after intravenous drug using (OR, 1.85 and OR, 4.03, respectively). In a study in New Mexico, prisoners tattooing was an important risk factor for HBV (OR, 2.3; 95% CI, 1.4-3.8) and HCV (OR, 3.4; 95% CI, 1.6-7.5) transmission.28 These ORs are near to the tattooing risk for HBV and HIV in our study.
Other studies that were conducted in Australia and Italy revealed that tattooing is important for HCV transmission (OR, 2.729; OR, 2.930). This risk was important in our study too (OR, 2.95), but there were other more powerful risk factors for HCV infection in our study such as IVDA and needle sharing. In a study in 2003 that was conducted among HCV-positive individuals referred to Ahwaz Jundishapour University Hospital, southwest of Iran, tattooing was found to be an independent risk factor of being HCV positive in about 3.5% of the cases.31
Anyway, it should be remembered that tattooing is an important risk factor for HBV, HCV, and HIV transmission, and in some countries, it is recommended that the fragmentary legislation be rewritten and made more effective.32 It is recommended that according to a ministerial order, only medical doctors should be allowed to procure a license for tattooing, as it is an invasive procedure.30
In prisons, there are many high-risk behaviors other than IDU and tattooing that can aid transmission of blood-borne infections. One of these behaviors is razor sharing for shaving and hairdressing. Our study showed that this behavior in Iranian prisoners is a powerful risk factor for HBV, HCV, and HIV infections (OR, 1.51 for HBV, 3.21 for HCV, and 3.29 for HIV). Some other studies also emphasize this fact,4,33 but it should be implied that there are not enough researches for this risk factor and more studies are needed to evaluate this risk factor.
Illegal Sex and Homosexuality
Illegal sex and homosexuality were not significant risk factors for HBV, HCV, and HIV infection in our study, and their significance is similar to the history of transfusion.
A study conducted in Iran to determine whether HCV infection of index cases increases intrafamilial transmission (sexual and nonsexual contacts) concluded that sexual transmission does not seem to play an important role in the spread of HCV infection,7 but a study that was conducted on homosexual prisoners in Ghana revealed that there is an association between homosexuality and HCV infection (OR, 3.1).34
A study that is conducted in Tehran (Iran) revealed that among the prisoners who reported no history of injecting drug use, HIV-1 prevalence has been 5.4%, and lack of condom use during sex has been significantly associated with infection (OR, 3.42). This study concluded that harm reduction programs, which have been started in Iran, should be urgently expanded particularly in correctional settings and strengthened by condom use promotion to prevent sexual acquisition or transmission of HIV-1.16 In a cohort study in Thailand on 1865 IVDAs, homosexuality in men (men who have sex with men) was an important risk factor for HIV infection (OR, 3.4).35 In another study in Brazil, this risk factor was important too (OR, 8.03).36 On the other hand, the conclusion of a study in Scotland has been that homosexuality is the commonest risk factor for HIV infection in the region, although the number of heterosexually infected patients has increased significantly in the last 5 years.37 A case-control study in Australia also has had the same results. It showed that homosexuality is a major risk factor for HIV (OR, 6.2).38
It should be noted that there are many various risk factors in prisons for transmitting blood-borne infections, that many of them may be undercover for us, and it should be emphasized that in Iranian prisons, intravenous drug abusing and sharing needle, razor, and tattooing equipments are the major risk factors for these infections, and harm reduction programs should be focused on these problems.
At the end, it should be stated that with this study, we evaluated the most important risk factors for hepatitis and HIV infections in these prisoners, and by this study, we cannot find the actual risk factor that leads to each prisoner's infection. Moreover, it should be considered that in this study, we used prison staff to gain information about risk factors that would seem potentially biased; but it was inevitable, perhaps it was better to repeat filling the questionnaire by 2 or more staffs to get better results.
1. Koziel MJ, Siddiqui A. Hepatitis B virus and hepatitis delta virus. In:Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases
. Philadelphia: Churchill Livingstone; 2005;1864-1890.
2. Merat S, Malekzadeh R, Rezvan H, et al. Hepatitis B in Iran. Arch Intern Med
3. Guimaraes T, Granato CF, Verella D, et al. High prevalence of hepatitis C infection in a Brazillian prison: identification of risk factors for infection. Braz J Infect Dis
4. Stauber R. Epidemiology and transmission of hepatitis C. Wien Med Wochenschr
5. Thomas DL, Ray SC, Lemon SM. Hepatitis C. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases
. Philadelphia: Churchill Livingstone; 2005;1950-1981.
6. Hakimzadeh K. Guidelines for the Prevention of Transmission of HBV, HCV, and HIV in Healthcare Settings
. 1st ed. Tehran: Nashr Seda Press; 2001:4-8.
7. Hajiani E, Masjedizadeh R, Hashemi J, et al. Hepatitis C virus transmission and its risk factors within families of patients infected with hepatitis C virus in southern Iran: Khuzestan. World J Gastroenterol
8. Alizadeh AH, Alavian SM, Jafari K, et al. Prevalence of hepatitis C virus infection and its related risk factors in drug abuser prisoners in Hamadan-Iran. World J Gastroenterol
9. Malekzadeh R, Khatibian M, Rezvan H. Viral hepatitis in Iran and the world: epidemiology, diagnosis, treatment and prevention. J Med Council of IRI
10. Merson MH, Piot P. Global perspectives on human immunodeficiency virus infection and acquired immunodeficiency syndrome. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases
. Philadelphia: Churchill Livingstone; 2005:1465-1477.
11. UNAIDS. Middle East and North Africa Fact Sheet: Geneva; 2005;1-2.
13. Field MG. HIV and AIDS in the former Soviet Bloc. N Engl J Med
14. Christensen PB, Krarup HB, Niesters HG, et al. Prevalence and incidence of bloodborne viral infections among Danish prisoners. Eur J Epidemiol
15. Weild AR, Gill ON, Bennett D, et al. Prevalence of HIV, hepatitis B and hepatitis C antibodies in prisoners in England and Wales: a national survey. Commun Dis Public Health
16. Zamani S, Kihara M, Gouya MM, et al. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran. AIDS
17. Malliori M, Sypsa V, Psichogiu M, et al. A survey of bloodborne viruses and associated risk behaviours in Greek prisons. Addiction
. 1998;93(2): 243-251.
18. Macalino GE, Viahov D, Sanford-Colby S, et al. Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons. Am J Public Health
. 2004;94(7): 1218-1223.
19. Decker MD, Vaughn WK, Brodie JS, et al. Seroepidemiology of hepatitis B in Tennessee prisoners. J Infect Dis
20. Chiramonte M, Trivello R, Renzulli G, et al. Hepatitis B virus infection in prisons. A seroepidemiological survey in prisoners and attending staff. J Hyg (Lond)
21. Crofts N, Stewart T, Hearne P, et al. Spread of bloodborne viruses among Australian prison entrants. Br Med J
22. Stark K, Herrmann U, et al. A syringe exchange program in prison as prevention strategy against HIV infection and hepatitis B and C in Berlin, Germany. Epidemiol Infect
23. Weber U, Schneider W. Syringe exchange in Germany. Subst Use Misuse
24. Dolan KA, Wodak A. HIV transmission in a prison system in an Australian state. Med J Aust
25. Dolan K, Rutter S, Wodak AD. Prison-based syringe exchange programs: a review of international research and development. Addiction
26. Jurgens R. Another review of prison-based needle exchange programs published. Can HIV AIDS Policy Law Rev
27. Dolan KA, Biji M, White B. HIV education in a Siberian prison colony for drug dependent males. Int J Equity Health
28. Samuel MC, Doherty PM, Bulterys M, et al. Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol Infect
29. Hellard ME, Hocking JS, Crofts N. The prevalence and the risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities. Epidemiol Infect
30. Babudieri S, Longo B, Sarmati L, et al. Correlates of HIV, HBV and HCV infections in a prison inmate population: results from a multicentre study in Italy. J Med Virol
31. Hajiani E, Hashemi J, Masjedizadeh R, et al. Seroepidemiology of hepatitis C and its risk factors in Khuzestan province, southwest of Iran: a case-control study. World J Gastroenterol
32. Loimer N, Werner E. Tattooing and high risk behaviour among drug addicts. Med Law
33. Sawayama Y, Hayashi J, Kakuda K, et al. Hepatitis C virus infection in institutionalized psychiatric patients: possible role of transmission by razor sharing. Dig Dis Sci
34. Adjei AA, Armah HB, Gbagbo F, et al. Correlates of hepatitis C virus infection among incarcerated Ghanaians: a national multicentre study. J Med Microbiol
35. Beyrer C, Jittiwutikarn J, Teokul W, et al. Drug use, increasing incarceration rates, and prison-associated HIV risks in Thailand. AIDS Behav
36. Hacker MA, Friedman SR, TElles PR, et al. The role of "long term" and "new" injectors in a declining HIV/AIDS epidemic in Rio de Janeiro, Brazil. Subst Use Misuse
37. Mackenzie AR, Laing RB, Urbaniak SJ, et al. Epidemiology and outcome of HIV infection in North-East Scotland (1985-1997). J Infect
© 2007 Lippincott Williams & Wilkins, Inc.
38. Crofts N, Hay M. Entry of HIV infection into a population of injecting drug users. Med J Aust