Prison inmates are reported to exhibit higher rates of disease morbidity, mortality, and health care utilization than the general population (1, 2). The rates of infectious diseases such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are reported to be particularly elevated in prison (3–5). This excess is largely attributed to the high concentration of inmates with a history of injection drug use (6, 7). Other risk factors that may place inmates at increased risk of HCV either prior to or following incarceration include intranasal cocaine use, prostitution, and other high-risk sexual activity (6, 7). The situation regarding blood-borne viruses and intravenous drug users (IDUs) in prisons in low- and middle-income countries is unclear because accurate data are limited and difficult to access. Indications that the situation might be more detrimental than in high-income countries include the fact that 90% of HIV cases live in low-income countries (8), that HIV prevalence is often higher in the general community in low-income countries than in high-income countries (8), and that three-quarters of the estimated 13 million IDUs live in low- and middle-income countries (9). Because of the seriousness of HBV, HBC, and HIV infections among inmates, it is important to know the prevalence of these infections.
We determined the frequency of HIV, HBV, and HCV in 6371 male prisoners aged 16 and above examined between January and December 2006 in five prison blocks in the western part of Libya (Table 1). The study protocol was approved by the Centre of Disease Control Research Committee Board. The hepatitis B surface antigen (HBsAg) (ELISA, AXSYM, Abbott, Chicago, IL, USA), the HCV antibodies (ELISA, AXYSM version 3.0, Abbott, Chicago, IL,USA), and the HIV antibody tests were conducted at the reference laboratory of the Centre of Disease Control; positive HIV cases were confirmed by western blot (Genlab Diagnostic, Redwood City, CA, USA). The frequencies were 6.9% for HBsAg, 23.7% for the hepatitis C virus, and 18.2% for HIV. Nine hundred seventy-seven prisoners (15.3%) had positive results for more than one of the infections, and 95 (1.5%) had positive results for three viruses. Eighty-four percent of HIV-positive prisoners were hepatitis C–positive as well (Table 2).
Table 1.
Socio-demographic background among male prisoners
| Nationalityb | Marital statusd | |||||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Agea | Libyan (%) | Non-Libyan (%)c | P | Married (%) | Not married (%) | P |
| 16–25 | 453 (7.4) | 911 (14.8) | <0.05 | 194 (3.2) | 1170 (19.1) | <0.05 |
| 26–40 | 2514 (40.9) | 1474 (24) | <0.05 | 1156 (18.9) | 2832 (46.1) | <0.05 |
| >40 | 484 (7.9) | 303 (5) | <0.05 | 643 (10.5) | 144 (2.3) | <0.05 |
| Total | 3451 (56.2) | 2688(43.8) | 1993 (32.5) | 4146 (67.5) | ||
233 prisoners with unidentified age.
215 prisoners with unknown nationality.
104 prisoners with unknown marital status.
96.7% of non-Libyan prisoners are of African origin.
Table 2.
Seroprevalence of antibodies to human immunodeficiency virus (anti-HIV), hepatitis B surface antigen (HBsAg), and antibodies to hepatitis C virus (anti-HCV) in prisoners
| Age group (years) | HBsAg positive | P | Anti-HCV | P | Anti-HIV | P | |||
|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|||||||
| Libyana (%) | Non-Libyan (%) | Libyan (%) | Non-Libyan (%) | Libyan (%) | Non-Libyan (%) | ||||
| 16–25 | 21 (0.3) | 44 (0.7) | <0.05 | 66 (1.1) | 18 (0.3) | <0.05 | 48 (0.8) | 26 (0.4) | <0.05 |
| 26–40 | 154 (2.5) | 122 (2) | <0.05 | 1060 (17.3) | 78 (1.3) | <0.05 | 789 (12.9) | 104 (1.7) | <0.05 |
| >40 | 32 (0.6) | 38 (0.6) | <0.05 | 180 (2.9) | 59 (0.9) | <0.05 | 132 (2.2) | 29 (0.5) | <0.05 |
96.7% of non-Libyan prisoners are of African origin.
These results showed a significantly higher seroprevalence of HIV and HCV among the prison inmates in Libya as compared with the seroprevalence of these infections previously reported in the general healthy group in Libya (10, 11) or in prisons in developed countries (12).
Many studies from different parts of the world indicated that the prisoners represent a high-risk group for blood-borne diseases. Homosexuality and high-risk behaviors among prisoners may contribute to the transmission of these diseases. However our study neither allows us to determine whether the inmates acquired the diseases while in prison nor does it provide direct evidence of transmission of infectious diseases in prison. Furthermore, as a rule, there are inadequate medical facilities and staff in the prisons in Libya, and access to appropriate care outside the Libyan prison system is very difficult for the inmates. This epidemiological study represents a disturbing reality and is a public health issue. It is clear that inmates have a substantial risk of contracting these infections while they are in prisons. The current study underscores a critical need for local prevention activities. The urgency is augmented by the marked rise in HIV sero-incidence documented among IDUs in Libya and is surely a harbinger of worsening conditions for a variety of opportunistic infections and other sexually transmitted diseases.
Hisham Ziglam
Department of Infectious Diseases, Central Hospital
Tripoli, Libya
Email: hisham.ziglam@gmail.com
Abdel-Aziz Zorgani
Department of Microbiology and Immunology, Faculty of Medicine, Tripoli University, Tripoli, Libya
Ahmed Balouz
Department of Chest Medicine, Aboseta Hospital
Tripoli, Libya
Abdel Hafidh Abudher and Omar Elahmer
National Centre of Disease Control, Tripoli, Libya
References
- 1.Gore SM, Bird AG, Cameron SO, Hutchinson SJ, Burns SM, Goldberg DJ. Prevalence of hepatitis C in prisons: WASH-C surveillance linked to self-reported risk behaviours. QJM. 1999;92:25–32. doi: 10.1093/qjmed/92.1.25. [DOI] [PubMed] [Google Scholar]
- 2.Laurence J. The role of prisons in dissemination of HIV and hepatitis. The AIDS reader. 2005;15:54–5. [PubMed] [Google Scholar]
- 3.Long J, Allwright S, Barry J, Reynolds SR, Thornton L, Bradley F, et al. Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in entrants to Irish prisons: a national cross sectional survey. BMJ. 2001;323:1209–13. doi: 10.1136/bmj.323.7323.1209. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Macalino GE, Vlahov D, Sanford-Colby S, Patel S, Sabin K, Salas C, 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;94:1218–23. doi: 10.2105/ajph.94.7.1218. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Ruiz JD, Molitor F, Plagenhoef JA. Trends in hepatitis C and HIV infection among inmates entering prisons in California, 1994 versus 1999. AIDS. 2002;16:2236–8. doi: 10.1097/00002030-200211080-00023. [DOI] [PubMed] [Google Scholar]
- 6.Acedo A, Campos A, Bauza J, Ayala C, Jover M, Herrero L, et al. HIV infection, hepatitis, and syphilis in Spanish prisons. Lancet. 1989;2:226. doi: 10.1016/s0140-6736(89)90415-7. [DOI] [PubMed] [Google Scholar]
- 7.Bird AG, Gore SM, Burns SM, Duggie JG. Study of infection with HIV and related risk factors in young offenders’ institution. BMJ. 1993;307:228–31. doi: 10.1136/bmj.307.6898.228. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Dolan K, Kite B, Black E, Aceijas C, Stimson GV. Reference Group on HIVAP, Care among Injecting Drug Users in D, Transitional C: HIV in prison in low-income and middle-income countries. Lancet Infect Dis. 2007;7:32–41. doi: 10.1016/S1473-3099(06)70685-5. [DOI] [PubMed] [Google Scholar]
- 9.Aceijas C, Stimson GV, Hickman M, Rhodes T. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS. 2004;18:2295–303. doi: 10.1097/00002030-200411190-00010. [DOI] [PubMed] [Google Scholar]
- 10.Elzouki AN. Hepatitis B, C and HIV infection in Libya: A national population-based nationwide seropepidemiological survey. The Libyan Journal of Infectious Diseases. 2007;1:132–3. [Google Scholar]
- 11.Arya S. Hepatitis B virus among Libyan health care workers. Saudi Med J. 2001;22:930. [PubMed] [Google Scholar]
- 12.Bellis MA, Weild AR, Beeching NJ, Mutton KJ, Syed Q. Prevalence of HIV and injecting drug use in men entering Liverpool prison. BMJ. 1997;315:30–1. doi: 10.1136/bmj.315.7099.30. [DOI] [PMC free article] [PubMed] [Google Scholar]