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Seroprevalence of and Risk Factors Associated With Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus Among Prisoners in Iran

Pourahmad, Morteza MD*; Javady, Abbassali MD; Karimi, Iraj MD; Ataei, Behrooz MD; Kassaeian, Nazila BSc

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Infectious Diseases in Clinical Practice: November 2007 - Volume 15 - Issue 6 - p 368-372
doi: 10.1097/IPC.0b013e318142ce16
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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.

Hepatitis B

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

Hepatitis C

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.


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).

Risk Factors, ORs, and the Number of Cases With Hepatitis B (total = 46)
Risk Factors, ORs, and the Number of Cases With Positive HCV Ab (total = 497)
Risk Factors, ORs, and the Number of Cases With Positive HIV Ab (total = 92)
The Most Important Risk Factors and Their ORs


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

Razor Sharing

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.


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