SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON PREVALENCE OF PULMONARY TUBERCULOSIS AND HUMAN IMMUNO- DEFICIENCY VIRUS AMONG INMATES IN NSAWAM MEDIUM SECURITY PRISON IN GHANA FRANCES MAGDALENE TINNA SESAY (10585005) A DISSERTATION SUBMITTED TO SCHOOL OF PUBLIC HEALTH, COLLEGE OF HEALTH SCIENCES, UNIVERSITY OF GHANA, IN PARTIAL FULFILLMENT FOR THE AWARD OF MASTER IN PUBLIC HEALTH DEGREE JULY 2016 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I hereby declare that excluding precise references which have been duly acknowledged, this submission is my own work towards my Masters of Public Health dissertation and that, to the best of my knowledge, it contains no material previously published by another person nor material which has been accepted for the award of any other degree of the University or elsewhere. FRANCES MAGDALENE TINNA SESAY (STUDENT NAME) ……………………………………………. SIGNATURE ……………………………………………. DATE DR. REUBEN K. ESENA (ACADEMIC SUPERVISOR) ……………………………………………. SIGNATURE …………………………………………… DATE University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This piece of work is dedicated to the Almighty and wonderful God for granting me blessings, favor and grace to go through this course; I am forever grateful almighty Father. This work is also dedicated to Mr. Ponsford Ekor Pyne-Cummings for being my source of strength and inspiration for the entire period. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT I am most grateful to The Lord God Almighty, for His sovereign grace and direction throughout my Masters of Public Health (MPH) program. I am also immensely indebted to WHO/TDR for providing the funding to pursue this course through the Office of Research Innovation and Development (ORID) University of Ghana. I am grateful to my supervisor, Dr. Reuben K. Esena and Dr. Ivy Mensah for their encouragement, guidance and immense contribution. I wish to extend my profound gratitude to all my lecturers who imparted me with the needed knowledge, skills and attitude required in Public Health especially those at the Department of Health Policy Planning and Management (HPPM) and the entire School of Public Health staff for their various contributions and support. I appreciate the Management of Ghana Prisons Service (GPS), the Regional Commander and Officers in charge of the Nsawam Medium Security Prisons, Dr. Nii Nortey Hanson Nortey and the entire staff of NTP, management and staff of NACP and Mr. John Kennedy of DCL laboratory products for their cordiality, support and technical assistance during my field work. I am forever grateful to my parents Mr. Gabriel Joseph Sesay and Mrs. Agatha Yealie Sesay, my source of strength Mr. Ponsford Pyne-Cummings, my adorable gem Michaella Doris Tanga, siblings and all my loved ones for their prayers, motivation, support and patience during my study. To my wonderful TDR 2015 first cohort colleagues Ruth, Vincent, Yves, Daniel, Kingsley, Alfred, Nouhoum and Selina together we made it to the END! Not forgetting HPPM colleagues class of 2015 especially Samuel Kotie Amon and Adomah.Bandoh May the Almighty God continue to bless us all in our daily endeavors. University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Introduction: Tuberculosis and Human Immuno- deficiency Virus (HIV) infections represent two of the greatest threats in African prison. They are both endemic diseases in Sub-Saharan Africa. They have been associated with poor sanitation, overcrowding, poor ventilation, sharing of sharps and other body fluids. Tuberculosis is caused by bacteria whilst HIV is caused by a virus. Objective: The objective of this study is to determine the prevalence of pulmonary tuberculosis (PTB) and human immuno-deficiency virus (HIV) infection among prisoners. Methodology: A cross sectional study design was used to assess the prevalence of PTB and HIV infection among prisoners in Nsawam Medium Security Prison. GeneXpert MTB/RIF was used for sputum analysis for PTB and first response HIV test kit w a s u s e d for those who consented to VCCT for HIV. Relationship between socio-demographic variables and a positive screening test for the TB and HIV was assessed using bivariate and multivariate logistic regression models. Results: There were 5 (3.4%) positive TB cases out of a total of 149 (76.4%) presumptive PTB prisoners who were able to produce sputum for GeneXpert analysis. The overall PTB prevalence was 3101 per 100,000 prison population. Eleven (5.8%) out of 189 inmates were HIV positive among which 2(18.2%) had TB co-infection. The prevalence of HIV infection among TB infected inmates was 40% (2/5) and that of presumptive TB cases was 1.3% (2/149). Sex and HIV were risk factors significantly associated with HIV and TB respectively. Conclusion: Prevalence of TB and HIV are high in Nsawam Medium Security Prison with possible active transmission of both disease within the prison. There was also high prevalence of HIV among presumptive TB cases and therefore strong cooperation between prison authorities University of Ghana http://ugspace.ug.edu.gh v and the NTP and NACP is strongly recommended to develop appropriate interventions to reduce transmission of these diseases. Keywords: Pulmonary Tuberculosis; TB/HIV co-infection; Prisons; Ghana University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENT ............................................................................................................. iii ABSTRACT ................................................................................................................................... iv TABLE OF CONTENTS ............................................................................................................... vi LIST OF TABLES ......................................................................................................................... ix LIST OF FIGURES......................................................................................................................... x LIST OF ABBREVIATIONS ........................................................................................................ xi DEFINITION OF TERMS .......................................................................................................... xii CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background .................................................................................................................... 1 1.2 Tuberculosis ................................................................................................................... 3 1.2.1 Global Burden of Tuberculosis ............................................................................... 5 1.2.2 TB Burden in Africa ................................................................................................ 5 1.2.3 TB Burden in Ghana ............................................................................................... 6 1.3 Human Immune-Deficiency Virus ................................................................................. 7 1.3.1 Global Burden of HIV ............................................................................................. 7 1.3.2 Health Effects of HIV ............................................................................................. 8 1.4 Prevalence of TB and HIV ............................................................................................. 8 1.5 Problem statement .......................................................................................................... 9 1.6 Conceptual Framework ................................................................................................ 11 1.7 Research Questions ...................................................................................................... 14 1.8 Justification of Study .................................................................................................... 14 1.9 Objectives of the Study ................................................................................................ 15 1.9.1 General Objective .................................................................................................. 15 1.9.2 Specific Objectives ................................................................................................ 15 CHAPTER TWO ........................................................................................................................ 16 LITERATURE REVIEW ............................................................................................................ 16 2.1 Tuberculosis ................................................................................................................. 16 2.2 Prevalence of TB in Prisons ......................................................................................... 18 2.3 Prevalence of HIV in Prisons ....................................................................................... 20 University of Ghana http://ugspace.ug.edu.gh vii 2.4 Prevalence of TB and HIV in Prisons .......................................................................... 22 2.5 Socio-Demographic Factors ......................................................................................... 25 2.6 Prison Related Factors .................................................................................................. 26 2.7 Morbidity Related Factors ............................................................................................ 27 2.8 Conclusion .................................................................................................................... 28 CHAPTER THREE ..................................................................................................................... 29 METHODS ................................................................................................................................. 29 3.1 Introduction .................................................................................................................. 29 3.2 Study Area .................................................................................................................... 29 3.3 Study design ................................................................................................................. 33 3.4 Inclusion Criteria .......................................................................................................... 34 3.5 Exclusion Criteria ......................................................................................................... 34 3.6 Variables ....................................................................................................................... 36 3.7 Sampling ....................................................................................................................... 37 3.7.1 Study population ................................................................................................... 37 3.7.2 Sample Size ........................................................................................................... 37 3.8 Quality control .............................................................................................................. 40 3.9 Data Collection ............................................................................................................. 41 3.9.1 Data collection procedure ..................................................................................... 41 3.9.2 Data gathering tool ................................................................................................ 41 3.9.3 Data entry and analysis ......................................................................................... 43 3.10 Ethical considerations ................................................................................................... 43 3.11 Communication of results ............................................................................................. 45 CHAPTER FOUR ....................................................................................................................... 46 RESULTS ................................................................................................................................... 46 4.1 Characteristics of inmates and study participants ......................................................... 46 4.2 Socio-demographic characteristics of TB suspects ...................................................... 47 4.3 Socio-demographic characteristics of HIV screened participants ................................ 47 4.4 Prison related characteristics of presumptive PTB cases .............................................. 52 4.5 Morbidity related characteristics of presumptive PTB cases ........................................ 53 4.6 Prevalence of TB and HIV Co- infection among inmates of Nsawam Medium Security Prisons ...................................................................................................................................... 56 4.7 Association of HIV and risk factors ............................................................................. 59 4.8 Bivariate and Multiple Logistic Regression Analyses of PTB Risk Factors ................ 60 University of Ghana http://ugspace.ug.edu.gh viii 4.9 Risk Factors association with PTB ............................................................................... 64 4.9.1 Socio-demographic factors associated with PTB .................................................. 64 4.9.2 Prison related factors ............................................................................................. 64 4.9.3 Morbidity related factors associated with PTB ..................................................... 65 CHAPTER FIVE ......................................................................................................................... 66 DISCUSSION ............................................................................................................................. 66 5.1 Background of inmates ................................................................................................. 66 5.2 Prevalence of PTB ........................................................................................................ 67 5.3 Prevalence of HIV ........................................................................................................ 68 5.4 Prevalence of TB and HIV co-infection ....................................................................... 69 5.5 Risks factors associated with PTB among inmates ...................................................... 70 5.6 Risk Factors associated with HIV among inmates ....................................................... 71 CHAPTER SIX ........................................................................................................................... 73 CONCLUSION AND RECOMMENDATION .......................................................................... 73 6.1. Conclusion .................................................................................................................... 73 6.2. Recommendation .......................................................................................................... 74 REFERENCES ............................................................................................................................ 76 APPENDICES ............................................................................................................................ 84 Appendix 1: Consent form .......................................................................................................... 84 Appendix 2: Questionnaire .......................................................................................................... 86 Appendix 3: Laboratory Form .................................................................................................... 91 Appendix 4: WHO TB Screening Questionnaire ......................................................................... 92 Appendix 5: Ghana Health Service Ethical Approval Certificate ............................................... 93 Appendix 6: Ghana Prisons Service Approval Letter ................................................................. 94 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 1: Study variables ................................................................................................................ 36 Table 2: Prevalence of Pulmonary TB and HIV among presumptive TB cases with socio- demographic characteristics .......................................................................................................... 49 Table 3: Prison related characteristics with presumptive PTB cases ............................................ 53 Table 4: Morbidity related characteristics of presumptive PTB cases .......................................... 54 Table 5: TB and HIV Co-infection and socio-demographic characteristics ................................. 57 Table 6: Association of HIV and risk factors ................................................................................ 59 Table 7: Factors associated with PTB among Presumptive PTB cases......................................... 62 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure 1: Conceptual framework ................................................................................................. 13 Figure 2: Map of Nsawam-Adoagyiri Municipality .................................................................... 30 Figure 3: Picture of Nsawam Medium Security Prison .............................................................. 33 Figure 4: Study design ................................................................................................................ 35 Figure 5: Distribution of TB symptoms among Presumptive, Screened and confirmed PTB cases ....................................................................................................................................................... 56 University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABBREVIATIONS AFB :Acid Fast Bacilli AIDS :Acquired Immune Deficiency Syndrome BCG :Bacillus Calmette Guerin BMI :Body Mass Index CXR :Chest X-Ray DOTS :Directly Observed Treatment Short-Course EPTB :Extra Pulmonary Tuberculosis GPS :Ghana Prisons Service HIV :Human Immuno-deficiency Virus MDG :Millennium Development Goals MDR :Multi-Drug Resistance MTB :Mycobacterium tuberculosis NACP :National Aids Control Program NTP :National Tuberculosis Control Program PTB :Pulmonary Tuberculosis SDG :Sustainable Development Goals SSA :Sub Saharan Africa TB :Tuberculosis UNAIDS :Joint United Nations Program on HIV/AIDS VCCT :Voluntary Counselling and Testing WHO :World Health Organization University of Ghana http://ugspace.ug.edu.gh xii DEFINITION OF TERMS A confirmed PTB patient or a PTB patient on anti-TB treatment: Is a person or inmate who is bacteriologically confirmed with at least one positive sputum sample for AFB or DNA of TB. Presumptive PTB case: Is an inmate whose cough duration was 2 weeks or more or cough was less than 2 weeks but with score of 3 or more on symptom screening, or score of 4 or more on symptom screening as per WHO screening tool. BM I: Body Mass Index is defined as weight in kilogram (kg) divided by height in meter square (m2). Prison inmate: Is defined as a person held in prison custody. TB defaulter: Is a person on anti-TB drugs who interrupts course of treatment for 4-8 weeks. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background Prisons worldwide are known for high rates of communicable diseases which affect both prisoners and prison staff; these rates exceed those in the general population (Levy, 1999; O’Grady, 2011). Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) are a major threat to prison health with HIV rates as high as 50%, and TB incidence rates on average 23 times higher than in the general population (Baussano et al., 2010). Populations most at risk of HIV and TB are often the more marginalized and more likely to be imprisoned; and people who use drugs (Jurgens, 2011). According to World Health Organization (WHO, 2007a) “all prisoners have the right to receive health care, including preventive measures equivalent to that available in the community”. Tuberculosis, commonly known as TB, is a bacterial infection caused by Mycobacterium Tuberculosis complex that could spread through the lymph nodes and bloodstream to any organ in the body (Abebe et al.,2011), although it is most often found in the lungs. The disease is transmitted from a sick patient to a healthy person through coughing, speaking and sneezing. Most infection occurs when the airborne droplets nuclei containing infectious Mycobacterium Tuberculosis are inhaled by a susceptible person (CDC, 2013). Its major symptoms are cough, lasting for more than two weeks, loss of weight, tiredness, night sweats, chest pain and chronic stage cough with bloodstained sputum. However, not all people who are exposed to TB can develop symptoms as the bacteria can live in an inactive form in the body. Overcrowding, poor ventilation and duration of exposure increase risk of transmission (Warrell, 2014a). Literature Review on Tuberculosis in Prisons, (WHO, 2008a) so far showed alarming TB rates among prisoners in countries such as University of Ghana http://ugspace.ug.edu.gh 2 Ethiopia, Ivory Coast, Cameroon, Malawi and Malaysia. The TB case rates found in prisons remained the highest among any population ever recorded (Baussano et al., 2010). Human Immuno-deficiency Virus (HIV) is the cause of Human Immuno-deficiency disease which leads to Acquired Immune Deficiency Syndrome (AIDS). AIDS was first recognized in the USA in 1981 and cumulative mortality from AIDS related infections to date is about 35 million (UNAIDS, 2016). Infective body fluids are blood, semen, vaginal fluid, breast milk, CSF and serous effusions. The chief routes of transmission are unprotected sex, mother to child transmission through vaginal delivery and breastfeeding, blood transfusion, sharing of sharps, needle stick injuries to healthcare workers and injections or treatments with unsterile needles, syringes, surgical apparatus or skin-piercing instruments and intravenous drug use with unsterile needles and syringes from one person to the other (Warrell, 2014b). Prisoners are known often to be housed in overcrowded facilities with inadequate ventilation, hygiene and sanitation (WHO, 2007b). The food that is provided are nutritionally inadequate and Health services may be weak or absent (Winetsky et al., 2014). Prohibited behavior such as the use of alcohol, drugs or sexual activities (without consent) may continue unchecked. Such conditions are suitable for the outbreak or occurrence and spread of epidemic diseases such as TB and HIV. Hence, prisons are often named as possible reservoirs of TB (Addis et al., 2015; Henostroza et al., 2013). The menace of TB in prisons still remains a persistent problem; rates among inmates remain much higher from 5 to up to 50 times than those of national averages across developed and developing world (Baussano et al., 2010). Prisoners constitute less than a quarter of society; a high proportion of them are poorly educated and socioeconomically disadvantaged. University of Ghana http://ugspace.ug.edu.gh 3 Therefore they are carrying with them into prison an increased risk of ill health, including a high risk of tuberculosis infection and disease. Overcrowding and prolonged exposure through long sentences promote tuberculosis. The use of drugs illegally, even though it is forbidden, is common, and the primitive and unhygienic use of injecting equipment’s. Same sex, whether voluntary or forced occurs, with rare use of condom (Abebe et al., 2011). The HIV epidemic further complicates control of tuberculosis in prisons. Prison conditions, tuberculosis, and HIV transmission are thus interconnected (USAID, 2013). This study therefore sought to assess the prevalence of Tuberculosis and HIV infection among inmates of the Nsawam Medium Security Prison. 1.2 Tuberculosis Basic facts about tuberculosis Tuberculosis (TB), is an airborne disease caused by Mycobacterium tuberculosis complex (MTBC). M. tuberculosis and seven identically related mycobacterial species (M. bovis, M. africanum, M. microti, M. caprae, M. pinnipedii, M. canetti and M. mungi) together comprise what is known as the MTBC. Majority of these species have been found to cause disease in humans. In Ghana, most of TB cases are caused by M. tuberculosis and M. africanum (CDC, 2013); (Abebe et al., 2011). This organism, also called tubercle bacilli can spread through the lymph nodes and bloodstream to any organ in the body. Pulmonary Tuberculosis (PTB) affects the lungs mainly. Most people who are exposed to TB seldom develop symptoms because the bacteria can live within the body in an inactive form. The disease is transmitted from a sick patient to another through coughing, speaking and sneezing. Infection occurs when the airborne droplets nuclei containing infectious M. tuberculosis are University of Ghana http://ugspace.ug.edu.gh 4 inhaled by a susceptible person. Overcrowding, poor ventilation and duration of exposure increase risk of transmission (Warrell, 2014a). Its major symptoms are coughs, which last for more than two weeks, loss of weight, tiredness, night sweats, chest pain and cough with bloodstained sputum. PTB in adult is mainly diagnosed through the collection of sputum sample. Due to the nature of the waxy coat of Mycobacterium cell wall, it retains an aniline dye (e.g. carbol fuchsin) even after discoloration with acid and alcohol; it is thus named Acid Fast Bacilli (AFB). This characteristic enables detection by microscopy. Even though this method has low sensitivity; it is widely applied and used globally, because it is simple, rapid and cost-effective. In resource limited settings, culture is used for definitive diagnosis of TB. However, it is much more expensive than microscopy, requiring a long incubation period and facilities for media preparation as well as skilled staff. GeneXpert MTB/RIF which serves as a rapid diagnostic test for TB offers prompt diagnosis within 2 hours and ensures early treatment. Compared to microscopy, it is expensive and needs trained personnel to carry out its operation. The other diagnostic method is chest x-ray (CXR) which is less applicable in low resource countries (Boehme et al., 2011; Jafari et al., 2009; Jittimanee et al., 2007; Campbell & Bah-sow, 2006; Fournet et al., 2006). Treatment and management of tuberculosis is mainly targeting five objectives which are; preventing death from active TB or its late effects; preventing TB relapse or recurrent disease; preventing the development of drug resistance and decreasing TB transmission to others. The drugs recommended for first line treatment of TB are safe and effective if properly used. In Ghana, these include rifampicin, ethambutol, isoniazid, pyrazinamide and streptomycin. The administration of treatment regimen has two phases, firstly, the intensive (initial) phase that consists of 4 drugs (rifampicin, ethambutol, isoniazid, and pyrazinamide) for the first 8 weeks for new cases and 12 weeks for re-treatment cases. During this phase of treatment, drugs must be University of Ghana http://ugspace.ug.edu.gh 5 collected and swallowed under direct observation of a health worker on a daily basis. Secondly, the continuation phase has at least 2 drugs (Rifampicin and isoniazid) that will be taken for 4-6 months. In this phase, drugs must be collected every month and self-administered by the patient, except for some conditions such as in defaulter or Multi-drug resistance (MoH, 2015; Abebe et al., 2011). The policy of TB treatment is called Directly Observed Treatment, Short-course (DOTS) which was adopted for the control of TB together and formulated global targets for the year 2000, in order to detect 70% of infectious new cases and curing of 85% of the detected infectious cases at the World Health assembly in 1991 (WHO, 2008b) 1.2.1 Global Burden of Tuberculosis Tuberculosis is a major public health concern despite all the achievements, efforts and interventions that has been made especially in achieving the Millennium Development Goal 6 (MDG 6). Mortality rate has fallen by 47% since 1990 with effective diagnosis and treatment, saving about 43 million lives between 2000 and 2014. The global incidence rate has fallen 18% lower than the level of 2000, however, it still remains ranked alongside with HIV as a leading cause of death worldwide. It was estimated in 2014 that 9.6 million people worldwide have fallen ill with TB across the various regions of the world of which South-East Asia and Western Pacific regions accounting for 58% and African Region 28%. India, Indonesia and China had the largest number of cases recording: 23%, 10% and 10% of the global total respectively (WHO, 2015). 1.2.2 TB Burden in Africa Africa accounts for 28% of the world’s cases in 2014, but the most severe burden relative to population with 281 cases for every 100 000 people, which is more than double the global average of 133. It was also not part of the WHO region that met the achievements of the MDG 6 with University of Ghana http://ugspace.ug.edu.gh 6 Ethiopia and Uganda as the 2 African countries of the high burden countries achieving the MDG 6 target in terms of prevalence, incidence and mortality. Of the 30 high burden TB countries in the World 9 are from Africa and most of these countries have a high prevalence of HIV (WHO, 2015) TB is a leading cause of high morbidity and mortality rates in adults in sub-Saharan Africa. Especially in the developing world where prisoners with poor background, malnourished and coupled with HIV are the most affected with TB (Campbell & Bah-Sow, 2006). 1.2.3 TB Burden in Ghana Ghana has been doing relatively well with regard addressing TB but it is still classified as one of the TB/HIV high burden countries (Falzon et al., 2015) The treatment success rate for TB in 2014 was 87% with the fastest electronic National TB prevalence survey conducted in 2014 with improvement in the diagnosis and treatment of the disease by equipping 8 Regional hospitals with GeneXpert installation and training, 50 light microscopes distributed to district hospitals and health centers, sputum smear microscopy training for 203 laboratory staff and the storage and dispensing of TB drugs at the facility level evidenced by a decline in the adverse treatment outcome showing a reflection of the successful interventions in place (MoH, 2015). The Ghana National TB prevalence survey was carried out in 2013 with an estimated prevalence of all forms of TB of 286 per 100,000 population with the disease burden resting on age 45 and above which accounts for approximately 78% with male predominance of 69%. Anti-Retroviral Therapy (ART) uptake has increased among TB/HIV co-infected patients from 11% in 2006 to 38% in 2014. However despite all the successes, there are challenges with high TB prevalence of 286 per 100,000 population, high case fatality rate of 7.5%, and a low case detection rate of 57.5 per 100,0000 which is evidenced by a consistent decline since 2009 when the highest notification rate was recorded. The TB case detection rate was placed at 20.7% which University of Ghana http://ugspace.ug.edu.gh 7 is 50% lower than the earlier estimate according to the National TB prevalence survey reports 2014 (MoH, 2015). Notwithstanding, National Tuberculosis Control Program (NTP) sees this continuous decline as a major challenge that requires greater efforts to push case notification towards achieving the targets of the SDG strategy- The End TB strategy. Targeted strategies of the National Tuberculosis Control Program (NTP) to deal with the challenges of low case detection include TB screening among high risk groups such as among the diabetics, prisoners and among HIV positive clients (MoH, 2015) 1.3 Human Immune-Deficiency Virus HIV is one of the greatest public health and social problems threatening the human race. The greatest burden is in sub-Saharan Africa. Human immunodeficiency virus (HIV) is the cause of Acquired immune deficiency syndrome (AIDS) global burden. AIDS was first recognized in USA in 1981 and cumulative mortality from HIV infection to date is 35 million (UNAIDS, 2016). Infectious body fluids for HIV are blood, semen, vaginal fluid, breast milk, CSF and serious effusions. The main routes of transmission are unprotected sex, mother to child transmission, blood transfusion, sharing of sharps, needle stick injuries to health care workers and injections or treatments with unsterile needles, syringes, surgical apparatus or skin-piercing instruments (Warrell, 2014b). 1.3.1 Global Burden of HIV Currently 36.7 million people approximately are living with HIV with tens of millions of people having died of AIDS-related causes since the beginning of the epidemic (UNAIDS, 2016). While new cases have been reported in all regions of the world, approximately 70% are in sub- Saharan Africa (UNAIDS, 2014). Most people living with HIV or at risk for HIV have limited or no access University of Ghana http://ugspace.ug.edu.gh 8 to prevention, care and treatment and yet there is still no available cure (WHO, 2013). The prevalence of HIV is currently 1.8% in Ghana which is however showing an increase in the burden of the disease since the last two years (MoH, 2016a) 1.3.2 Health Effects of HIV HIV primarily affects people who are in their peak reproductive years; about 38% of new infections are among those under 25 years (WHO, 2013a). It does not only disturb the health of individuals, but also that of households, communities and the overall development growth of nations. Many of those hit by HIV do also suffer from other infectious diseases, food insecurity and other grave difficulties and complications. Global prevalence of people ages 15-49 who are infected has levelled since 2001 and was 0.8% in 2004 (UNAIDS, 2014). About 1.2 million people died of AIDS in 2014, a 42% decrease since 2004. The deaths toll has declined partly due to antiretroviral treatment (ART) scale-up. HIV has been classified as a leading cause of death worldwide and the number one cause of death in Africa. The new infections globally has declined by 35% since 2000. Sixty-one (61) countries, have had decrease in new HIV infections by more than 20%. It is estimated that there are about 2.1 million new infections and approximately 5600 new infections per day in 2015 giving a fall of 6% since 2010 (UNAIDS, 2016) 1.4 Prevalence of TB and HIV Tuberculosis (TB) is the commonest opportunistic infection and number one cause of death in HIV patients in developing countries, and accounts for about 40% of all manifestations seen in HIV patients. About 25% to 65% of patients with HIV/AIDS have TB of any organ and which accounts for about 13% of all HIV related deaths worldwide (UNAIDS, 2014). In 2014, TB killed 1.5 million people (1.1 million HIV-negative and 0.4 million HIV-positive), HIV’s death toll was estimated at 1.2 million, which included the 0.4 million TB deaths among HIV positive people. University of Ghana http://ugspace.ug.edu.gh 9 There were 9.6 million people who were ill with TB worldwide in 2014. Globally, 12% of the 9.6 million new TB cases were HIV-positive with 74% of the cases been recorded in Africa with 390,000 deaths in 2014 (WHO, 2015). HIV/AIDs ranked Ghana at 34 with 49.90 death rate per 100,000 population (World life expectancy, 2015). The prevalence of Tuberculosis which includes HIV is currently 282 per 100,000 population making it a high burden of disease in the country (WHO, 2015). Ghana is one of the 30 countries classified as high burden countries in terms of TB/HIV in the 2016-2020 (Falzon et al., 2015) which means that there is an increased need to investigate and treat positive patients living with Tuberculosis and HIV as a co-morbid condition. 1.5 Problem statement Tuberculosis (TB) remains a major global health problem causing ill-health amongst millions of people and ranks alongside HIV as a leading cause of death worldwide (WHO, 2015). In populations subject to confinement, such as those in prisons, nursing homes and psychiatric hospitals, TB constitutes a major public health problem. However, some studies have emphasized the effects of the neglect of strategies of TB control in the prison system (WHO, 2013b). Identifying and successfully treating all tuberculosis (TB) patients is the cornerstone of the global strategy to stop TB (WHO, 2009). Yet, a key obstacle to achieving this goal has been that many people with TB are currently being ‘missed’ by health systems (WHO, 2014). It is projected that the majority of these cases could be among the poorest people of the world. Discovering undiagnosed TB was therefore greatly emphasized by WHO and mentioned as a priority area of research (WHO, 2014) Prisoners are at an unreasonably high risk of TB and HIV infection (WHO, 2007a). Many prisoners could be suffering from TB, especially in sub-Saharan African prisons, where the prison cells are mostly overcrowded, poor health services available, coupled with HIV infection and malnutrition University of Ghana http://ugspace.ug.edu.gh 10 are predominant (O’Grady et al., 2011a; O’Grady et al., 2011b). Earlier studies carried out in sub- Saharan African prisons reported TB prevalence ranging from 3.5% to 5.8% (Telisinghe et al., 2014; Henostroza et al., 2013) that reveal high TB and HIV co-infection with about 44% TB cases in South African prison (Telisinghe et al., 2014) and 37% in Zambian prisons (Henostroza et al., 2013) co-infected with HIV. In Ghana, prisoners are residing in overcrowded and often poorly ventilated environments (Baodu, 2014). The prison health services are constrained with inadequate skilled manpower and laboratory facilities for TB diagnosis (Ghana Prisons Service, 2015). Currently protocol for the screening of prisoners on entry, during incarceration or on exit are are not available. The diagnosis of TB is done by the infirmary and referral of prisoners to health facilities outside the prisons where further evaluation and management could be done (US Department of State, 2013). As a result, prisoners with TB in Ghanaian prisons are not timely diagnosed unless through passive surveillance (when they themselves report to the clinic) posing a serious risk not only for other prisoners but, also for visitors and the prison personnel, with ultimate risk to the general community. Estimating the prevalence of TB and HIV and their associated risks factors will help not only to improve TB control program in Nsawam Medium Security Prisons setting but also in designing strategies that will improve the overall TB control programs in the prison establishments. There is limited research work carried out on both TB and HIV in Ghanaian prisons. Previous studies from Ho (Kwabla et al., 2015) and national Ghanaian prisons (Adjei et al., 2008) reported 0.5% and 5.9% of TB and HIV respectively, which is higher than i n the general population. However, these studies were limited in scope in that the former was focused mainly on smear-positive cases using sputum smear microscopy and recommended the use of multiple diagnosing technique and a more sensitive approach whilst the latter did not include TB investigation. University of Ghana http://ugspace.ug.edu.gh 11 Due to the difference in socioeconomic, lifestyle and environmental conditions across prisons (Ghana Prisons Service, 2015) which could affect the distribution of TB and HIV infections it was deem to do another study in Nsawam Medium Security Prisons. The burden of TB and HIV in Nsawam Medium Security Prisons is yet to be studied. Therefore, this study was carried out at the Nsawam medium security prisons among inmates to determine the prevalence of Tuberculosis and HIV infection and assessing its associated risk factors and comparing it with the prevalence in the general population. Taking into account the priority placed on risk groups for routine screening for TB as the residents of prisons are considered as risk groups (WHO, 2013b). These diseases which impact on the wellbeing of prisoners are therefore worth investigating in other to help the early detection and prompt treatment and reduce the number of deaths caused by these diseases. Furthermore, such a research would help National Tuberculosis Control Programme (NTP) to implement ways of screening these vulnerable groups of people in the Ghana prison setting. 1.6 Conceptual Framework The conceptual framework underlying this study analyses the prevalence of Tuberculosis (PTB), HIV and; TB and HIV coinfection as shown in figure 1. Prisons are incubators for infectious diseases considering the fact that they have limited access to health and are overcrowded hence a fertile ground for airborne diseases such as TB and other sexually transmitted diseases like HIV. Gender, marital status, sexual habits and low socioeconomic status has been linked to the incidence of both TB and HIV. It has also been shown that education has a significant role to play as most of prison studies have revealed high illiteracy rate among prisoners. This compounds the prison related factors thereby increasing the risk of contracting such diseases. Prevalence rate of TB and HIV is higher among prisoners than in the general population due to the confinement and other University of Ghana http://ugspace.ug.edu.gh 12 prison related factors such as, poor ventilation and poor medical facilities and feeding, frequency of imprisonment, duration of incarceration and sharing cell with a TB patient. History of contact with a positive PTB case and previous incarceration has been reported to have a significant association with the diagnosis of TB in prisons. Similarly, socioeconomic status like occupational and educational level may also influence certain lifestyles like sharing of sharps, intravenous drug use and not using condom. This could lead to the spread of blood borne diseases such as HIV among prisoners, increasing their chances of infecting others and even reinfection. Finally, co-morbidity related factors like HIV coinfection, number of TB symptoms present and treatment support could influence the tendency of one contracting and spreading the diseases. University of Ghana http://ugspace.ug.edu.gh 13 Prison related factors  Housing environment  Ventilation in the prison cell  Number of Prisoners per cell  History of previous imprisonment  Frequency of imprisonment  Duration of incarceration  Sharing cell with a TB patient  Availability of prison health services Socio-demographic factors  Sex  Location of residence  Age  Marital status  Educational status  Occupation/profession Prevalence of Human Immuno-Deficiency Virus (HIV) / Tuberculosis (TB) Life style & risk Factors  Alcohol consumption  Duration of tobacco Smoking  Intravenous Drug use  History of contact  Sharing of Sharps  Condom Use Morbidity related factors  Number of TB symptoms present  HIV co-infection  Malnutrition  Previous history of TB  Treatment support Figure 1: Conceptual framework University of Ghana http://ugspace.ug.edu.gh 14 1.7 Research Questions The research questions were: 1. To what extent is the prevalence of tuberculosis among inmates? 2. To what extent is the prevalence of HIV among inmates? 3. What is the prevalence of TB and HIV co-infection among inmates? 4. What are the risk factors associated with TB and HIV transmission? 1.8 Justification of Study Prison populations are known to have an extensive turnover (Liebling et al., 2010), and a strong association between TB prevalence in correctional facilities and the community has been reported in several contexts (Kazi et al., 2010) . Prisons especially in Africa continue to have an unrecognized spread of these diseases which eventually have ripple effect on the general population when inmates are released to their communities. Furthermore, there is little data and information on the level of prevalence of tuberculosis and HIV transmissions in many prisons in Ghana especially the Nsawam Medium Security Prison. This study involved a cross section of inmates of the Nsawam Medium Security Prison who gave information on their social and economic status before incarceration and of whom diagnosis were made in relation to their TB and HIV status. The findings of the study aimed to sensitize various categories of people - including prisoners and prison staff - of the need to regularly know their status, and relevant agencies – such as National Tuberculosis Control Programme (NTP), Ghana Prisons Service (GPS) and Management of Nsawam Medium Security Prison, Ghana Health Services – of the need to ensure timely detection and treatment and hence reduce the spread of the infection. Additionally, the study was carried out to provide information on the prevalence of TB, HIV and, University of Ghana http://ugspace.ug.edu.gh 15 TB and HIV coinfection amongst inmates and also the risk factors associated with the spread of these diseases within the confines of the prisons. This would also not only contribute to knowledge in the field but also help in policy making and other stakeholders’ preventive and curative interventions regarding the welfare of the inmates in other to reduce the spread of the disease among inmates. 1.9 Objectives of the Study 1.9.1 General Objective The general objective of this study was to determine the prevalence of Pulmonary Tuberculosis and Human Immuno-deficiency Virus among inmates of Nsawam Medium Security Prisons in Eastern Region of Ghana. 1.9.2 Specific Objectives The specific objectives of the study were to: 1. Determine the prevalence of Tuberculosis among the inmates 2. Assess the prevalence of HIV among the inmates 3. Determine the prevalence of TB and HIV co-infections among inmates 4. Assess the risk factors associated with TB and HIV transmission. University of Ghana http://ugspace.ug.edu.gh 16 CHAPTER TWO LITERATURE REVIEW This chapter reviews available literature on the prevalence of TB and HIV in prisons. The purpose of the review is to provide insight into the burden of TB and HIV in the context of prisons. Identifying and describing the major socio-demographic factors, prison related factors and morbidity related factors to the contracting of TB and HIV as documented in the scientific literature. 2.1 Tuberculosis Tuberculosis (TB) is a chronic, infectious disease which still kills 1.5 million people annually (WHO, 2015). Tuberculosis is well-known to be a disease of poverty, affecting those who live in overcrowded, inadequately ventilated residence, and those who have compromised immunity to fight against it in terms of their immune or nutritional status which cause them to be prone to the infection and making them susceptible to the disease (Manzoor et al., 2009). TB was declared a global emergency in the year 1993. Ever since, an appreciable amount of effort has been made using different strategies to curtail the spread of the disease but it still remains a major public health problem (Abebe et al., 2011). TB and HIV are of major concern among prison inmates, particularly in low- and intermediate income countries. The settings in developing countries makes TB and HIV a major problem in prisons (Dara et al., 2009). Studies have documented limitations to TB control in prisons (Waisbord, 2010; Baussano et al., 2010). Some of the challenges preventing adequate provision of TB care in prisons as documented by Waisbord ( 2010), includes insufficient resource allocation for prison health care, neglected living conditions in prisons, lack of coordination between national University of Ghana http://ugspace.ug.edu.gh 17 TB program and prisoners low level of knowledge on TB. Global TB incident cases increased from 9.4 million in 2009 to 9.5 million in 2014. Of the estimates in 2014, South-East Asia and Western Pacific Regions collectively accounted for 58% whilst African Region had 28% cases, with most severe burden relative to population 281 new cases per 100 000 population on average, which is more than double the global average of 133 (WHO, 2015). The MDG 6 and global fund in TB control were part of concerted global actions to reduce the lethal effects of TB that ended in 2015 with the target of halving the incidence, prevalence and mortality of TB been achieved globally but not in the African region as only 3 regions (Region of the Americas, the South-East Asia and the Western Pacific Regions) were able to achieve it (WHO, 2015). However Ghana and other developing countries were unable to achieve the target which is however attributed to the HIV/AIDS epidemic as evidenced in the case of Ghana. Ghana is not part of the 22 burden high burden countries of TB but part of the high burden countries of TB and HIV (Falzon et al., 2015). TB is the leading cause of death amongst HIV patients accounting for one-third of AIDS related deaths with the death toll falling by 32% since 2004 (UNAIDS 2016). It was recommended by WHO that early diagnosis and supervised treatment of patients in communities would serve as TB control strategies (WHO, 2009). However, the poor health systems in prisons contributes to prisoners being threatened to be reservoirs for TB and HIV transmission outside the community (Dara et al., 2009). A study done in Brazilian prisons to evaluate TB screening score recommends that in addition to TB screening among prisoners at entry into prisons and passive case detection, active case detection and prompt treatment is of significance (Fournet et al., 2006). University of Ghana http://ugspace.ug.edu.gh 18 Prisons have been identified with rapid transmission of bacterial, viral, fungal and parasitic infectious diseases of the skin, gut, genitals and respiratory system (Pollini et al., 2009). Surveillance data from Eastern European prisons indicates that TB causes significant morbidity and mortality in prison inmates and staff (O’Grady et al., 2011). 2.2 Prevalence of TB in Prisons The menace of TB in prisons remains a persistent problem. The occurrence of active TB in prisons is reported to be much higher than the average levels reported for the resultant general population. In a survey of TB control in Europe, undertaken in 2006, it was estimated that European prisons notify TB at an average rate of 17 times more than in the general population, ranging between 11 times more in western Europe to 81 times higher in eastern Europe (Aerts, Hauer, Wanlin, & Veen, 2006). TB in prisons is a major cause of death and limitation for TB control in the country, especially in countries with a high incidence of TB (Dara, Chorgoliani, & de Colombani, 2014). Inmates of prisons as opposed to the general population, are more likely to have multiple risk factors for infection with M. tuberculosis and progression to the disease state. They are also more likely to have drug resistance TB. Therefore extraordinary efforts are needed to mitigate the personal and public health toll created by these risk factors as the overcrowding of people in congregate settings such as prisons has resulted in explosive outbreaks of TB (Manzoor, Tahir, & Anjum, 2009) In the USA, the burden of latent TB infection increases as new immigrants from high prevalence areas move to America. Similarly having more of low immune prisoners’ increases the burden of TB (Manzoor, Tahir & Anjum, 2009). Evidence also suggests that treatment of latent infection reduces the risk of progression to active tuberculosis, especially in high-risk groups, such as University of Ghana http://ugspace.ug.edu.gh 19 people living with HIV. However, prisoners are considered to have inadequate access to health services and proper nutrition and thereby resulting in the rapid progression from latent to active TB (Manzoor, Tahir & Anjum, 2009). Several studies have confirmed the high prevalence of PTB in prison populations and suggested the need for urgent preventive measures. For in s t ance , in a cross-sectional study to determine the prevalence of PTB in Ethiopia, the point prevalence was 2.03%. In this study, 384 out of 1,624 inmates were screened for PTB and 33 (8.59/%) were smear positive. During the study period there were no prisoners on anti-TB medication (Addis et al., 2015). Similarly in an epidemiological study done in Southern Brazilian prison with 1900 inmates using culture and sensitivity analysis to diagnose inmates, 72 inmates were positive giving a prevalence of 3.8%. Of the 72 positive samples, 68 (94.4%) were both culture and smear sputum positive, four (5.6%) were only sputum smear positive. Seventeen of the TB cases (23.6%) had at least one prior TB episode and were considered as retreatment cases. Thus, the incidence was 2.9% (55 of 1,900 inhabitants) which indicates the high burden of TB incidence among prisoners (Kuhleis et al., 2012). In another study examining the prevalence, risk factors and social context of active PTB among prison inmates in Tajikistan that surveyed 1,317 inmates in two prison facilities, 59 cases of active PTB (point prevalence: 4.5%; 95%CI 3.4–5.7) were diagnosed on the basis of clinical and radiographic criteria. Of these, 36 (61.0%) were smear positive. Sputum culture was positive in 16 cases (27.1%), with forty-seven cases (79.7%) having radiographic findings suggestive of TB. Symptoms of TB were present in 30 (50.8%) cases. However the disease prevalence was not significantly different between the two prison facilities (Winetsky et al., 2014). University of Ghana http://ugspace.ug.edu.gh 20 Sanchez et al., (2009) screened 1696 prisoners in 3 Rio de Janeiro (RJ) prisons using a standardized questionnaire. The results revealed an overall prevalence of active TB of 2.7% with twelve of the 46 previously treated for TB. Therefore the prevalence of TB cases was 2%. Of the 46 TB cases, 19 had AFB-positive smear(s) and 13 were smear-negative/culture- positive with the other 14 inmates (30.4%) having a bacteriologically unconfirmed TB, but with a favorable response to anti-tuberculosis treatment. Chest X-ray (CXR) lesions were often extensive: 43% (20/46) of cases had bilateral and/or excavated lesions, of which 14 with excavated lesions were confirmed by sputum smear, giving a prevalence of 354.8/100 000. This study showed a high prevalence (2.7%) of active TB among inmates entering the prisons from police remand centers and further recommended the need for entry screening (Sanchez et al., 2009). TB effects in prisons goes beyond that of the confines of prison and must not be ignored. TB cases occurring in the community in high and mid-low income countries, respectively, have been found to be as a result of TB transmission within prisons (Dara et al., 2014; WHO, 2012). TB in prisons accounts for about 25% of a given country TB burden globally. WHO estimated that the prevalence of TB in prisons are 10-100 fold higher than the prevalence in the general population (Abebe et al., 2011). TB control in prisons in Sub-Saharan African (SSA) countries poses great challenges and hence increases the prevalence of active TB within and outside of the prison walls (O’Grady et al., 2011; Barbour, Clark, Jones, & Veitch, 2010). 2.3 Prevalence of HIV in Prisons At the end of 2015, an estimated 36.7 million people worldwide were living with HIV infection. In the same year, 2.1 million new infections and 1.1 million AIDS-related deaths had occurred (UNAIDS, 2016). HIV prevalence among prisoners is presumed to be higher than that of the general population although there are limited data to account for it; available data shows that HIV University of Ghana http://ugspace.ug.edu.gh 21 prevalence among prisoners is 6 to 50 percent higher (UNAIDS, 2009). A lot of HIV-infected prisoners have come from sectors of society that have a higher than average HIV prevalence (e.g., drug users) and so enter prison already infected with HIV. Those who enter prison uninfected with HIV have an increased risk of acquiring HIV due to certain risky behaviors such as men having sex with men and sharing needles for drug use or sharp objects for tattooing (Dara et al.,2009). Maruschak (2015) stated that by the end of 2010, state and federal prisons held a reported 20,093 inmates with HIV/AIDS less than that recoded in 2009 20,880 which led to a decline in the estimated rate of HIV/AIDS from 151 cases per 10,000 inmates in 2009 to 146 per 10,000 in 2010. Among these in 2010 18337 were males whilst 1756 were females compared with 19027 males and 1853 females in 2009. These results show that there has been a decline in the HIV/AIDS trend which is mostly attributed to the recommendations given in an earlier analysis done in 2007 by the same author. In another study done on HIV and prisons in Sub-Saharan Africa acknowledges the fact of little information currently available for Africa and the absence of data for HIV-positive prisoners for most African countries. However the existing data suggested a high prevalence among African prisoners compared with the general adult population. The study made use of randomly collected data in a number of countries which showed HIV prevalence in prisons ranging from 2.7% in Senegal and 9% in Nigeria to 27% in Zambia based on voluntary and ELISA testing and a South African prevalence about 40% HIV-positive among inmates, while HIV prevalence among adults is estimated at a much lower rate of 25%. Other countries, such as Cameroon has 12% prevalence and 28% in Côte d’Ivoire among inmates, which double or triple the HIV prevalence among the adult population in these countries. Mauritius recorded 5% prevalence University of Ghana http://ugspace.ug.edu.gh 22 among prisoners, which is almost 50 times the prevalence among the general adult population. Data were available only for a limited number of countries and there was no provision of systematic data on the magnitude of the pandemic. Countries with the highest HIV prevalence rates, such as those in southern Africa; Botswana, Lesotho, Swaziland, Zambia and Zimbabwe were without available data (UNODC, UNAIDS & WHO, 2006) 2.4 Prevalence of TB and HIV in Prisons The menace of TB in prisons remains a challenge, rates among inmates remain much higher from 5 to 50 times more than those of the countries both developed and the developing nations (Barbour et al., 2010). Prisoners globally are at a disproportionately high risk of tuberculosis as well as HIV infection which is a strong risk factor for tuberculosis (Telisinghe et al., 2014). Prisoners may hail from deprived communities with high rates of tuberculosis. HIV promotes the progression of infection from latent to active TB both recently acquired and latent infection and is known to be the most potent risk factor known for the activation of latent TB (Bill, 2015). The combination of the high prevalence of both TB and HIV in prisons is responsible for a high mortality rates amongst prisoners (UNODC, UNAIDS & WHO, 2006). HIV and TB have been identified as a major health problem for prisons around the world owing to the fact that prisons have characteristics that can increase the risk of the transmission of these diseases. A study done to review literature on prisons showed that in Tanzania’s prisons, 41% of inmates had active TB with a rate of TB/HIV co-infection ranging from 26% in Tanzania to 74% in Malawi, the same study observed that some countries in Africa have extremely high rates of TB in their prisons population such as 4,000/100,000 in Zambia and 3,797/100,000 in Botswana. In Cameroon, Ivory Coast and Malawi, the amount of active TB ranged from 3.5% to 5.8%. The University of Ghana http://ugspace.ug.edu.gh 23 study found that Zambia prisons showed 9.5% MDR yet there was nearly no drug resistance in the Botswana study (WHO, 2008a; Banda, Gausi, Harries, & Salaniponi, 2009). In a cross-sectional survey, 266 prisoners who consented to participate in the study performed in Kelantan,-Malaysia underwent two-step TST (Tuberculin Skin Test) and were screened for active TB symptoms. Among prisoners with and without HIV the overall LTBI (Latent Tuberculosis Infection) prevalence was 87.6%, with significantly lower TST reactivity among HIV-infected than non-HIV-infected prisoners (83.6% vs. 91.5%, P < 0.05); nonetheless, TB symptoms were similar (16.9% vs. 10.1%, P = 0.105) among the two groups (Margolis. B et al., 2013). Disproportionately in another study done in Pakistan on the prevalence of HIV and TB among jail inmates in Lahore, among 3851 inmates who participated in the study 2.3% inmates were HIV positive which was a very high prevalence than the national one. Also amongst 52.2% of inmates who had cough, none tested smear positive; which was explained primarily by the fact that the study was done in camp jail which is a temporary abode for prisoners that are locked for their hearing in courts of provincial towns (Manzoor et al., 2009). As opposed to the study done in Pakistan, a South African study on the need for routine TB screening in prisons used a cross-sectional approach involving only male prisoners. Of 1046 eligible male prisoners , 981 (93.8%) who consented to be part of the study were screened using chest radiography and 2 sputum samples for microscopy and culture and an anonymous HIV antibody testing performed using urine specimens. Amongst the 968 not on anti-TB treatment and with sputum culture results, 34 (3.5%; 95% confidence interval [CI] 2.4–4.9%) were culture positive for M. tuberculosis. The HIV prevalence was 25.3% (242/957; 95% CI 22.6–28.2%). With reference to the gold standard of positive sputum culture, cough of any duration had a sensitivity of 35.3% and specificity of 79.6%. Chest X-ray (CXR) was the most sensitive single screening University of Ghana http://ugspace.ug.edu.gh 24 modality (sensitivity 70.6%, specificity 92.2%). The authors concluded that undiagnosed tuberculosis and HIV prevalence was high in the prison, and that the need for routine screening for tuberculosis at entry into the prison, and intensified case finding among existing prisoners was imperative (Telisinghe et al., 2014). Similarly in a study done in North Gondar Prison Ethiopia using a criteria of history of cough for one week or more, fluorescence microscopy for sputum analysis, fine needle aspiration cytology (FNAC) for those with significant lymphadenopathy and a Pre and post HIV test counseling provided after written consent, found that out of the total of 250 prisoners, 26 (10.4%) prisoners were TB positive giving a point prevalence of 1482.3 per 100,000 populations of smear positive TB among the TB suspects. Of all the inmates who participated and volunteered for HIV testing, a total of 19(7.6%) were found to be reactive for the HIV antibody test, and 9(47.4%) had TB co- infection. The prevalence of HIV infection in TB infected inmates was 34.6% (9/26). It was concluded that there is a high prevalence of TB in North Gondar Prison with possible active transmission of TB within the prison and a high prevalence of HIV among the TB suspects. Suggesting the need for robust cooperation between prison authorities and the national tuberculosis control programs to develop locally appropriate interventions to reduce transmission (Wondimeneh, Muluye, & Belyhun, 2012). Concurrently a study was done in North Gondar zone prison Northwest Ethiopia which looked at the record of TB and HIV prevalence and treatment success rate from 2002 to 2011 and found a prevalence ranging from 579 to 2623 per 100,000 population. Of 114 TB patients screened from 2009 to 2011 for HIV,14(12.3%) tested positive with a prevalence of TB and HIV co-infection ranging from 163 in 2009 to 288 in 2010 per 100,000 population. Giving a very high rate of TB and TB/HIV co-infection among inmates than the national rate (Moges et al., 2013). University of Ghana http://ugspace.ug.edu.gh 25 2.5 Socio-Demographic Factors Social and economic background of prisoners before incarceration has been found to have an increased risk of acquiring and developing TB (Kuhleis et al., 2012; Moges et al., 2012). Inmates originating from poor communities where TB is endemic have been found to be at increased risk of acquiring and developing TB (Union, 2006). Ali, Haileamlak, Wieser, & Pritsch (2015); Unit (2015) and Kazi, Shah, & Jenkins (2010) identified low education, homelessness, excess alcohol use, low income as risk factors for TB among prisoners. These factors have adverse effect on the immune system and also increase the exposure and vulnerability to infection and development of latent TB to active form. Fuge and Ayanto (2016) revealed higher PTB cases were found to be among young adults prisoners, who were between 15–35 years. Recognition that TB depends largely on social and economic determinants of health is crucial to achieve full control and elimination (Glaziou, et al., 2015). Factors such as smoking, alcohol abuse, diabetes, indoor air pollution, and malnutrition, like HIV, are impacting on TB epidemiology impeding faster progress toward its control (Lonnroth et al., 2011; Lienhardt et al., 2012). Reductions in levels of smoking, alcohol abuse, malnutrition, and indoor air pollution will likely be associated with reduction in TB infection and disease. Ultimately, education, health promotion, universal health coverage (Moreno-Serra and Smith 2012). Nonetheless, the burden of TB remains high and affects disproportionately poor and disadvantaged populations’ worldwide (Squire et al. 2006). In Malawi, Chipeta et al. (2009) revealed that condom use does not make much difference in the likelihood of a woman being infected with HIV. It was further reported by Chipeta et al. (2009) that HIV prevalence among women who said they have never used a condom and those who used condom some time is 15% each. In contrast, men who never used condom have a lower University of Ghana http://ugspace.ug.edu.gh 26 prevalence of HIV than those who did use a condom at some time. 2.6 Prison Related Factors Prisoners globally are at a disproportionately high risk of tuberculosis as well as HIV infection which is a strong risk factor for tuberculosis (Telisinghe et al., 2014; Dara et al., 2014) revealed that TB in prisons is a major cause of death and limitation for TB control in the country, especially in countries with a high incidence of TB. In this light there are many reasons which may result to TB transmissions in prisons. Fuge and Ayanto (2016) identified all PTB cases to be males and explained that the male prisoners may be at greater risk of acquiring the infection and becoming the source of transmission, due to the high overcrowding and poor housing condition of living compared to their female counterparts which are less populated. The study Fuge and Ayanto (2016) further revealed that smear positive PTB in prisoners from rural areas among farmers was higher than those from urban area. The length of incarceration was strongly associated with an increased odds of latent MTB infection (Hussain et al., 2003) .In Malaysia the prevalence of LTBI was extraordinary high in this sample of Malaysian prisoners, regardless of their age or HIV status (Al- Darraji et al., 2014). Dara et al. (2015) attributed TB transmissions to factors including but are not limited to, insufficient laboratory capacity and diagnostic tools, interrupted supply of medicines, weak integration between civilian and prison TB services, inadequate infection control measures, and low policy priority for prison healthcare. However, factors relating to living and crowding conditions as well as the length of stay in prison did not show any level of significance with PTB prevalence (Fuge & Ayanto, 2016) 2.7 Morbidity Related Factors Prisoners are the most vulnerable group that suffers high burden of communicable and non- communicable diseases. TB and HIV are excessive in correctional facilities and HIV-related University of Ghana http://ugspace.ug.edu.gh 27 immune suppression increases exposure and likelihood of reactivation of latent to active TB, (Margolis et al., 2013). A study done in Ghanaian prisons showed a higher prevalence of HIV, hepatitis and STI among prisoners than that seen in the general public (Adjei et al., 2008) The existence of other diseases such as HIV causes reduced immunity which eventually leads to an individual been at risk of TB infection. In a study evaluating TB screening methods in Brazil showed an independent prediction of TB with cough of 3 weeks or more, chest pain, BMI less than 20 and a history of TB treatment (Fournet et al., 2006). In a study done in Eastern Ethiopia, chest pain and duration of cough showed a significant association with PTB, with those recording cough of 4 o r m o r e weeks duration recording a higher prevalence than those with duration of cough less than 4 weeks. This study reveals a high degree of association between TB symptoms and prevalence of PTB (Abebe et al., 2011) HIV/AIDS in Sub-Saharan Africa has increased the spread of TB and HIV in prison. Being underweight or malnourished and a present or former prisoner were associated with higher risk for MTB infection with inmates moving from one cell prison to another and even upon discharge into the community pose an increased threat to other prisoners and the larger society (Hussain et al., 2003). The health of inmates is very vital in achieving the end TB strategy 2030 because undiagnosed and untreated TB can be spread not only among prisoners but staff of the prisons, visitors, University of Ghana http://ugspace.ug.edu.gh 28 judiciary staff and the community as a whole when they are eventually released into the communities (Reid et al., 2012;Barbour et al., 2010;Dara et al., 2014). WHO (2012) noted that a rapid reduction in TB incidence, prevalence and mortality in excess of what has been achieved historically requires more effective implementation of existing diagnostic tools and the development and widespread use of a highly effective and safe new vaccine or prophylactic treatment (PT) to prevent reactivation of TB disease among infected people. 2.8 Conclusion From the above review of literature it was apparent that the TB and HIV transmission are very high among prisoners due to the closed and overcrowded environment coupled with the illegal sexual and unsafe practices going on within the walls of the prisons. These diseases places a lot of burden on inmates and prison authorities which affects the quality of health care services and also the life of the inmates. It could be observed from the literature review that studies cited were mainly from developing countries in East and Southern Africa with a few in West Africa. Thus, very limited studies exist on the prevalence of TB and HIV among inmates in West Africa. This study therefore becomes relevant as it will not only bridge the knowledge gap in the area but also provide useful information on the prevalence of TB and HIV among inmates in Ghana for inmates, Prison authorities, National TB control Program (NTP) and policy makers in the health sector. University of Ghana http://ugspace.ug.edu.gh 29 CHAPTER THREE METHODS 3.1 Introduction This chapter describes the research methods and design used in the study, the setting and context under which the study was conducted as well as the target population of the study. It further explains various steps for collecting the data for the study as well as ethical considerations observed. 3.2 Study Area Profile of the study area The Nsawam-Adoagyiri Municipality (Fig 2) is one of the twenty-six administrative Districts in the Eastern Region of Ghana. It lies at the South Eastern part of the Eastern Region and covers a land area of about 205 sq km. The Municipality before its separation by the Legislative Instrument (LI 1839) into two (2) in September 2012, was called Akwapim South Municipality. The name Akwapim South was given to the new district created out of the then Akwapim South Municipality and is now called Nsawam-Adoagyiri Municipality. It was upgraded from District to a Municipality in January, 2008. (MoH, 2016b). In terms of spatial interaction, it is bordered to the south by the Ga West District in the Greater Accra Region and to the North by Ayensuano District, to the West by Upper West Akim District and the East by Akwapim South District. (MoH, 2016b). The Municipal capital Nsawam, is a gap town along the main highway linking the coastal lands to the Northern part of the country that is the Accra-Kumasi Road. University of Ghana http://ugspace.ug.edu.gh 30 The Municipality consists of four (4) sub municipals namely: Adoagyiri, Djankrom, Nsawam and Panpanso with about 120 communities. The current projected population estimated is Ninety-One Thousand Two Hundred and Sixteen (91,216) (Health, 2016b). With regards to the provision of health care services, the municipality is endowed with different types of health facilities that engage in health service delivery and provide different kinds of services. The health facilities available in the municipality provide health care services include one Municipal Hospital, six Health Centres, two private hospitals and five Community- based Health Planning and Services (CHPS) compounds. The others include two Mission health facilities (Christian Health Association of Ghana (CHAG)), an Orthopaedic Centre and one optical centre. (MoH, 2016b) Nsawam Prison Figure 2: Map of Nsawam-Adoagyiri Municipality University of Ghana http://ugspace.ug.edu.gh 31 Nsawam Medium Security Male and Female Prisons The study was carried out at the Nsawam Medium Security Prison (figure 3) located in Eastern region of Ghana. Nsawam is a town located in the Eastern Region of Ghana approximately 40 km northwest of Accra, the capital of Ghana (www.prisonministryghana.org). This facility resembles that of the Maximum Security facility but with less emphasis on internal fortification. Until the provision of a maximum prison facility in 2011, the Medium Security facility used to hold high sentence and aggressive prisoners. This is the only facility of such nature in the country established on a one (1) mile square plot of land located at the outskirts of the Nsawam Township. It used to be the largest among the 45 prison establishments in Ghana, and had the highest population of both staff and inmates in comparison with populations of other prisons across the country before the commissioning of the Ankaful Maximum Security Prison in 2011. The prison comprise of both male and female prisons which administratively is governed by two Officer in Charge (OIC) one male (for the male prison) and a female (for the female prison) with a regional commander for the Eastern region overseeing the operations of the prisons within the region which happens to double as the OIC for the male wing of the prisons. Between 2007 and 2010, Nsawam Medium Security Prison reported the highest number of death cases of about 367 prisoners which resulted from HIV/AIDS, TB, anemia, malnutrition, hypertension, typhoid and other poor welfare related issues (Boadu, 2014). Hence, the choice of Nsawam Medium Security Prison as the site for this proposed work. Nsawam Medium Security Male Prison was established in 1960 out of government decision to relieve overcrowding in the existing Central Prisons. The prison received its first inmates on 10th October, 1960 with CSP J.K. Arhin-Acquah as first Officer-In-Charge. It was finally commissioned in 1961 with capacity of 851 prisoners and an average of 38 cells and 20 prisoners University of Ghana http://ugspace.ug.edu.gh 32 per cell. Whilst the Female Prison was opened on 10th December, 1973. It is the biggest female prison in the country that provides safe custody for female prisoners to seek their welfare and reformation (Ghana Prisons Service, 2015). Administratively, Nsawam Medium Security Prisons is governed by the Akwapim South Municipal Assembly. However, the prisons is an institution under the Ghana Prisons Service (GPS) that is responsible for the safe custody of prisoners in Ghana, including their welfare, reformation and rehabilitation, and in the broader sense, it is under the jurisdiction of the Ministry of the Interior. Based on the level of security and nature of reformation activities undertaken at the various establishments across Ghana, Nsawam Medium Security Prison is classified as a Central Prisons where all categories of prisoners are kept. It has skill training facilities to equip prisoners with mainly self-employable skills for their effective reintegration into society after incarceration. Therefore, Nsawam Medium Security Prison take custody of long-sentenced prisoners. Both prisons have an infirmary which caters for the health needs of the prison staff and inmates. The male infirmary has an established laboratory facility which caters for minor laboratory tests, a DOTS center with a focal person for TB and a staff population of 15 with an isolation unit for infectious diseases TB is part of the category hence inmates are kept in the isolation unit during the intensive phase of the TB chemotherapy. The female side lacks a laboratory facility and a DOTS center and relies solely on referral to the Nsawam Government Hospital for diagnosis and treatment of TB cases as it is done with the HIV management of cases. The female staff population of the infirmary is currently 3. University of Ghana http://ugspace.ug.edu.gh 33 Figure 3: Picture of Nsawam Medium Security Prison 3.3 Study design This study was a quantitative cross-sectional study. Data were collected from randomly selected prisoners of the Nsawam Medium Security Prison aged 15 years and above during the period of 6th to 17th June, 2016. The recruited inmates who consented to participate in the study were interviewed using semi-structured questionnaire. Figure 4 shows diagrammatic representation of study design and data collection approach. The information was used to estimate the point prevalence of PTB and HIV infection, identify risk factors associated with PTB and HIV infection and transmission, and possible associations were drawn to identify risk factors (predictors). Table 1 describes the study variables and how they will be operationalized. University of Ghana http://ugspace.ug.edu.gh 34 3.4 Inclusion Criteria Prisoners who were mentally fit, willing to participate, above or equal to 15 years old and had ≥ 2 weeks duration of cough or ≥1 week duration of cough with a score of 3 or more on the WHO screening tool were included in the study. In addition, PTB patients, who were on anti-TB treatment during the study, were included to determine the prevalence. 3.5 Exclusion Criteria Prisoners, who had ≤ 1 week duration of cough, unwilling to participate and/or PTB patients during the time of data collection were excluded from the study. University of Ghana http://ugspace.ug.edu.gh 35 Study approval Cross sectional study Ethics Quantitative study 3400 Males and 73 Female in Prison N =3527 Random sample of inmates with history of cough and screened with WHO Questionnaire (N=258) On treatment at time of study TB: N=3; HIV: N = 6 Symptoms not suggestive (Non-PTB suspects) (N=63) Those with symptoms suggestive of PTB (PTB suspects) as per WHO TB screening tool (N=195) Not Interviewed (Non- Respondents) (N=63) Interviewed for PTB/HIV risk factors as per study questionnaire (N=195) Informed consent Did not produce sputum but interviewed for TB risk factor (N=46) VCCT (N=189) Produced sputum sample for (GeneXpert) (N=149) HIV positive (N=11) GeneXpert positive (N=5) No scientific fraud/falsification Study Results Figure 4: Study design University of Ghana http://ugspace.ug.edu.gh 36 3.6 Variables The table below shows the description of the study variables and how they were operationalized. Table 1: Study variables Independent Variable Dependent Variable Socio-demographic factors - Sex - Location of residence - Age - Marital status - Educational status - Occupation/profession - Religion - Nationality - Ethnicity Tuberculosis HIV TB/HIV coinfection Prison related factors - Housing environment - Ventilation in the prison cell - Number of prisoners per cell - History of previous imprisonment - Frequency of imprisonment - Duration of incarceration - Sharing cell with a TB patient - Availability of prison health services Tuberculosis Life style & risk Factors - Alcohol consumption - Duration of tobacco smoking - Intravenous drug use - History of contact - Sharing of Sharps - Condom use Tuberculosis HIV TB/HIV coinfection Morbidity related factors - Number of symptoms present - HIV co-infection - Previous history of TB - Treatment support Tuberculosis HIV TB/HIV coinfection University of Ghana http://ugspace.ug.edu.gh 37 2 3.7 Sampling 3.7.1 Study population The study population comprised of all male and female prisoners aged 15 years and above in the Nsawam Medium Security Prison during the study period who were willing and eligible to be part of the study. Prisoners who already have PTB and were on TB treatment during the study period were not tested for TB but were included for the interview and for the estimation of prevalence. All prisoners who were unwilling to participate were excluded from the study. 3.7.2 Sample Size A sample of 195 prisoners were selected for inclusion in the study. The prevalence of TB and HIV in Ghana was last measured in 2014 at 282 per 100,000 population (MOH,2015). Since that of prisons was not available for Ghana and Nsawam to be specific, the researcher used the national prevalence. Using a Z-value of 1.96, prevalence (p) of 0.282, a q value of 0.718 and a precision of 0.08 due to limited resources and time of data collection, 20% for compensating to incompleteness and unwillingness to participate. The sample size for the prison inmates was calculated using the following formula (Naing et al, 2006): n = 𝑍 pq 𝑑2 Where: n = sample size Z = 1.96 is the standard score for the confidence interval of 95% P = proportion of people living with TB/HIV d = allowable error of 8% University of Ghana http://ugspace.ug.edu.gh 38 2 𝑍2 n = 𝑑2 pq = 1.96 0.082 X (0.282 x 0.718) = 121.536 N = 3.8416 0.0064 X0.2025 600.25 X 0.2025 121.5 = 122 Adjusting for 20% non-response rate, incomplete information and voluntary withdrawal: 122 x 0.2 = 24 Hence, Total sample size (N) = sample size (n) + 20% non-response rate ⟹ N = 122 + 24 = 146 Therefore the sample size determined for this study was approximately 150 inmates. 3.7.3 Sampling Method At the time of the study, about 3527 prisoners were held in the male and female prisons comprising of 3454 males and 73 females inmates respectively. It was more than the estimated sample size. An announcement was done during the day at counting of inmates from cell to cell and at night when they were in their cells for inmates with cough to identify PTB suspects. Study participants were randomly selected in a manner that is representative of cell categories, offense and sentence. Inmates were thus drawn from the four main different cells in the Nsawam Medium Security Prison. These comprise of: (1) convict cells; (2) remand/trial cells; (3) condemned cells and; (4) University of Ghana http://ugspace.ug.edu.gh 39 life/high sentence cells. The sentence type is based on the offense committed and it can be classified as high or low depending on the duration. In all 151 inmates were selected from the convict cells, 23 from remand/trial cells, 10 from the condemned cells and 11from life/high sentence cells. This strategy provided an equal chance of selecting eligible individuals, and reduced a chance of losing PTB suspects. All those who coughed were registered and screened using the WHO screening tool (appendix 4). The WHO screening tool has the following scores: 2 points each for cough lasting more than 2 weeks, sputum production and coughing up blood; and 1 point each for cough less than 2 weeks, weight loss, loss of appetite, chest pain, drenching night sweats, fever, history of contact with a TB case and history of smoking or alcohol use. An inmate was considered as a TB suspect when his/her cough duration was 2 weeks or more or cough was less than 2 weeks but with score of 3 or more on symptom screen, or score of 4 or more on symptom screen as per the WHO tool and TB suspects were interviewed and those who consented to VCCT had it done after the interview and results given. Of the eligible 3527 prisoners, 258 (7.3%) who had a cough and willing to be part of the study were screened using WHO TB screening tool. 195 (5.6%) prisoners regarded as the study population that had a score of 3 or more per the WHO screening tool were included in the study were interviewed on risk factors of both TB and HIV. Out of this number, 46 (23.6%) prisoners were unable to produce sputum for analysis and were referred for chest X-ray at the Nsawam Government Hospital. Non suspected inmates were not interviewed and as such were excluded. University of Ghana http://ugspace.ug.edu.gh 40 3.8 Quality control Training of fieldworkers Five research assistants and two medical laboratory scientist used for the study were trained prior to the commencement of the data collection. The training focused on: (1) ensuring that the field workers understood the objectives of the study; (2) building understanding on the survey tools and interpretation; (3) assessing capacity of field workers to perform the survey tasks. Simulated practice was done to build consensus and consistency on study tool understanding, interpretation and administration. Questionnaires were checked on the field for completeness at the end of each day. Pre-test of data collection tools A pilot study was conducted in the Nsawam Medium Security Prison prior to the main data collection to: identify potential problems in the questionnaire; ensure that the study tool reflected prison conditions; and ensure questions were clear and well understood by the inmates as well as being well formatted. Furthermore, the Principal Investigator of the study had in-depth discussion with the Commander and Staff Officer of the Nsawam Medium Security Prison on the study tool which resulted in great changes to the questionnaire. Necessary modifications to the data collection tool were made based on the pre-test and discussion with prison headship. University of Ghana http://ugspace.ug.edu.gh 41 3.9 Data Collection 3.9.1 Data collection procedure Entry into the prison was granted by the Prison Headquarters with a letter sent to the Nsawam Prison Commander. The researcher paid a courtesy call to the Commander and Officer in charge of both male and female prisons that gave permission to the operations officer to allow access to the prisoners especially those in condemn cells that need very high security escort. The infirmary staffs were informed by the Medical Director of Prisons about the research and had staff from the infirmary and inmates assist with the research. Data were collected using a structured interviewer-administered questionnaire with both closed and open ended questions that required written responses. The questionnaires were administered with the help of research assistants in the form of a face-to-face interview. VCCT was done to those who consented to it upon completion of the questionnaire and sputum sample containers were given to the inmates for sputum production in the ensuing morning for analysis. 3.9.2 Data gathering tool A structured pre-tested interviewer administered questionnaire was used in the study to collect data from inmates (appendix 2). The structured questionnaire was developed by the researcher based on the objectives of the study, conceptual framework and guided by literature review. Both closed and open ended questions were used to enable the researcher obtain as much information as possible on: socio-demographic information; tuberculosis screening information; PTB and HIV risk factors and; life-style and risk factors. HIV infection: Voluntary counselling and testing (VCCT) was done on individual basis for those who consented to be screened. Presence of HIV 1 and 2 was detected using a Rapid Diagnostic Test Kit (First Response® HIV 1-2-0) manufactured by Premier Medical Corporation Limited in University of Ghana http://ugspace.ug.edu.gh 42 India. Infirmary nurses wore gloves as data was collected. The Serial number of inmates was written in a notebook. The tip of the finger to be pierced was cleaned using an alcohol pad. The fingertip of the participant was squeezed and the cleaned area of the fingertip was pierced using a lancet. The lancet was discarded in a sharp box. The first drop of blood was wiped out with sterile cotton. 5microliters of blood was collected using a micro-pipette. Five microliters of the whole blood was added to the “S” well on the test kit and 2 drops of the assay buffer solution was added into the same well after which timing started. Results were read after 10 minutes for each inmate. A test was invalid if the line in the “C” (control) area does not appear. Invalid tests were repeated. A negative test had one line in the “C” and a positive result for HIV 1 and 2 had two color bands; one in the “C” and another in the “T”. The results were recorded on the questionnaire and in the notebook for the infirmary to do confirmatory test and follow up. Pulmonary Tuberculosis: Inmates who were able to produce sputum were provided with a clean, dry, screw capped universal specimen collection container bearing the same serial number as that of the questionnaire. Inmates were given instructions on the amount and type of sputum to produce. Early morning sputum samples before brushing or food were collected and transported to the Pathogen level 3 (P3) laboratory of the Noguchi Memorial Institute for Medical Research (NMIMR) for geneXpert analysis in ice chest with ice packs. A laboratory request form was completed for a sputum sample which accompanied sample collected from study participants and taken for analysis see appendix 3. GeneXpert analysis: The GeneXpert® is a new molecular test for TB by detecting the presence of TB bacteria, as well as resistance to the drug Rifampicin from sputum or CSF manufactured by Cepheid®. Each sputum container with sputum was assessed to for the type and color of sputum produced. According to the manufacturer’s instruction; 1.5 ml of the sample reagent supplied with University of Ghana http://ugspace.ug.edu.gh 43 the cartridge was added unto the sputum, the mixture was then shaken by hand and vortexed for 30 seconds to ensure all bacteria were suspended and allowed to stand for 15 mins, with intermittent manual mixing. The solution was transferred from the container into the Xpert cartridge using a Pasteur pipette, and loading of the cartridge onto the Xpert machine for analysis. The results are reported as MTB detected, not detected or indeterminate which referred to as positive or negative or error for M. tuberculosis respectively. The MTB detected results were placed in one of four categories; very low, low, medium, or high depending on the bacterial load. Rifampicin resistance results were reported as not detected, susceptible or resistant. At the end of the geneXpert analysis the sputum containers were autoclaved and incinerated as per the P3 lab requirements. 3.9.3 Data entry and analysis Data were entered into EpiInfo version 7 which was exported into STATA version 13 for analysis. Significance level was set at 0.05. The quantitative variables such as age, length of stay in the prison was summarized and presented using means and standard deviations. The qualitative data; gender, marital status, location, socio-economic status, history of fever, cough, vaccination, previously screened for TB, contact history, risk factors and knowledge of the disease was summarized and presented using frequencies, percentages, charts, graphs and figures. Relationship between socio-demographic variables and a positive screening test for the TB and HIV was assessed using bivariate and multivariate logistic regression models. Furthermore, other categorical independent variables were tested for relationship with TB using chi-square test. 3.10 Ethical considerations Ethical approval was sought from the Ethical Review Committee of the Ghana Health Service University of Ghana http://ugspace.ug.edu.gh 44 (GHS-ERC 70/02/16). Permission from the Ghana Prisons Service and the In-charges (OICs) of the Nsawam Medium Security Prison was sought. Informed consent was obtained from sampled prisoners and confidentiality/privacy assured before their engagement in the study. They were informed about the purpose, procedures, risks and benefits of participating in the study. Study participants were told that there were no risk and conflict of interest involved in participating in the study. The participants were however informed of possible minor discomforts in answering certain questions for which they may choose not to answer. For participants who could not read, the consent form was read and explained to them in the presence of an independent witness. Only participants who agreed to be part of the study were recruited for the study and required to sign or thumbprint a consent form as an indication of their willingness to participate. The participants were informed that there would be no consequences, forfeiting of healthcare or other benefit if they choose to withdraw from the study. Data collected for the study was kept confidential and used solely for the purpose indicated for the study. Data files were password protected. Hard copy and electronic data were stored securely in locked file cabinets without the names of the participants, and access was limited to the Principal Investigator and the supervisors of the study. Interviews and extraction of data from patients’ records were done only by trained Research Assistants and Principal Investigator. Sputum samples was discarded after testing in the laboratory and the blood sample for HIV was needle pricked which the rapid test was burnt in an incinerator after reading the results on a daily basis. Participants were informed that participation in the study was voluntary and they could withdraw from the study at any time without attracting any penalty. Participants were not coerced into taking part in the study. Study participants were given soap and toilet roll at the completion of the interview as a token of appreciation for their time spent answering the University of Ghana http://ugspace.ug.edu.gh 45 research questions and producing sputum. 3.11 Communication of results This master thesis was submitted and defended at the School of Public Health, College of Health Sciences, University of Ghana. The results will be published in international scientific peer review journals. It will also be presented to the School Library for other students to access it, the GPS authority and the management of Nsawam Medium Security Prison, NTP and NACP in Ghana and scientific conferences and meetings. University of Ghana http://ugspace.ug.edu.gh 46 CHAPTER FOUR RESULTS This chapter presents the findings of the study at Nsawam Medium Security Prison Nsawam. It provides report of analyzed data on Tuberculosis and HIV related factors together with the prevalence of TB, HIV and TB/HIV co-infection and risk factors for TB and HIV infections. 4.1 Characteristics of inmates and study participants There were 3527 prisoners comprising of 3454 males and 73 females in detention at the male and female prisons respectively. Out of this number, a total of 258 inmates (7.3%) comprising of 73 females and 185 males with history of cough who consented to be part of the study were screened using the WHO screening tool. One hundred and ninety-five (75.6%) of the 258 had symptoms suggestive of TB as per the WHO screening tool and all 195 were willing to continue with the study. Three (3) of the 258 inmates were currently on anti-TB treatment before the commencement of the study and were included in the calculation of the overall prevalence of TB among the screened inmates. Twenty-seven out of the 195 presumptive TB cases had prior history of TB of which 24 were diagnosed and treated during incarceration and had completed therapy for more than 6 months. From the 195 presumptive TB cases, 149 (76.4%) were able to produce sputum for GeneXpert analysis and the remaining 46 (23.6%) who could not produce sputum were referred to Nsawam Government Hospital for CXR and further evaluation. Of the 149 sputum samples screened with the GeneXpert, 5 (3.4%) were positive, with 2 having very low, 1 medium and 2 high bacterial load concentration. No resistance to rifampicin was detected. Thus, there were 5 inmates who were confirmed as having PTB. Two out of the 5 confirmed PTB inmates tested positive for HIV. The overall prevalence of PTB was 3.1% University of Ghana http://ugspace.ug.edu.gh 47 (8/258) or 3101 per 100,000 prison population and the prevalence among presumptive PTB cases was 2.6% (5/195) or 2564 per 100,000 population (Table 2). Out of the 195 presumptive TB cases, 189 consented to be screened for HIV of which 11(5.8%) tested positive with 9 (81.8%) of the 11 already diagnosed prior to the study and 6 (66.7%) currently on ART. The 2 new cases were referred for confirmatory test at the Nsawam Government Hospital see (Table 2) below. 4.2 Socio-demographic characteristics of TB suspects One hundred and seventy-two (88.2%) of the presumptive TB cases interviewed were males, the mean age of study participants was 40years (SD+/-13) with a range of 17-80 years. About (50.3%) of the inmates were married before incarceration and 30.3% were single whilst 19.5% had no education, 76.4% had a minimum of basic education. One hundred and sixty-seven (85.6%) were employed of which 82% were engaged in the informal sector such as trading, masonry, carpentry, hairdressing and tailoring. About 87.6% of the population were Ghanaians with 72 (36.9%) being Akans and 14 (7.2%) Hausa. The proportion of presumptive PTB cases among Ghanaians was higher than the other nationals and was significantly associated with PTB [P=0.014]. One hundred and fifty-nine (80.3%) were Christians whilst 1 (0.51%) was a traditionalist. Ninety-three (47.7%) had history of smoking with a mean duration of 11.5 years and a (SD +/- 10) years with more than half (50.5%) having a smoke duration of 10 years and above. Table 2 below is showing the socio- demographic characteristics of the respondents. 4.3 Socio-demographic characteristics of HIV screened participants Table 2 presents summary of association between HIV and socio-demographic characteristics. A total of 189 (96.9%) study participants consented to be screened for HIV. About 11/189 (5.8%) University of Ghana http://ugspace.ug.edu.gh 48 of the inmates that consented were HIV positive, out of which 87.8% were females with the burden (62.4%) of HIV prevalence between the ages of 25-44 years having the highest number (7) of HIV positives. More than half of the inmates (51.3%) were married and 26 (13.8%) were single with the highest (6) HIV positive occurring among the singles (54.5%) followed by that of the married 4 (36.4%). Most (59.3%) of them have at least basic education with 54.5% of the cases occurring within the same group with basic education. With regards employment, 88.4% were previously employed with 82% engaged in the informal sector with 11(100%) of the cases being in the informal sector employment category. Christianity was the dominant (80.4%) religion with 10 (90.9%) of the HIV positives being Christians. As shown in table 2 sex was significantly associated with HIV. Females had more than fifty times higher risk of contracting HIV compared to males [AOR=52.71, 95% CI=10.36-268.10] and after adjusting for other confounders, about seventy-four times the risk [AOR=74.99, 95% CI= 11.20- 502.32]. The proportion of HIV positive among female prisoners was significantly higher (39.1%) compared to male prisoners (1.2%) (p<0.001). Similarly marital status is also significantly associated with HIV infection as being single makes one exposed 16 times higher to HIV infection than being married (p<0.001). University of Ghana http://ugspace.ug.edu.gh 49 Table 2: Prevalence of Pulmonary TB and HIV among presumptive TB cases with socio-demographic characteristics Variable PTB Prevalence HIV Prevalence Presumptive TB cases (N=195) Respondents who produced sputum (N=149) *Respondents with TB (N=5) *Pearson χ2 HIV screened participants (N=189) *HIV prevalence *Pearson χ2 N (%) N (%) N (%) (P-value) N (%) N (%) (P-value) Sex Male 172 (88.2) 130 (87.2) 4 (3.1) χ2= 0.24 166 (87.8) 2 (1.2) χ2=53.01 Female 23 (11.8) 19 (12.8) 1 (5.3) (p=0.621) 23 (12.2) 9 (39.1) **(p<0.001) Age <25 13 (6.7) 9 (6.0) 0 (0) χ2=36.8 12 (6.3) 1 (8.3) χ2=0.59 25 – 34 67 (34.4) 45 (30.2) 3 (7.1) (p=0.918) 64 (33.9) 3 (4.7) (p=0.898) 35 - 44 56 (28.7) 44 (29.5) 1 (2.3) 54 (28.6) 4 (7.4) >45 59 (30.3) 51 (34.3) 1 (2.0) 59 (31.2) 3 (5.1) Marital status Married 98 (50.3) 71 (47.7) 2 (2.8) χ2=2.97 97(51.3) 4 (4.1) χ2=16.87 Divorced, 71 (36.4) (p=0.226) 66 (34.9) 1 (1.5) **(p<0.001) separated 57 (38.3) 1 (1.8) and widowed Single 26 (13.3) 21 (14.0) 2 (9.5) 26 (13.8) 6 (23.1) Education level None 38 (19.5) 29 (19.5) 1 (3.4) χ2=1.5 38 (20.1) 3 (7.9) χ2=1.37 Basic 118 (60.5) 88 (59.1) 4 (4.5) (p=0.683) 112 (59.3) 6 (5.4) (p=0.712) Secondary 31 (15.9) 26 (17.4) 0 (0) 31 (16.4) 1 (3.2) Tertiary 8 (4.1) 6 (4.0) 0 (0) 8 (4.2) 1 (12.5) University of Ghana http://ugspace.ug.edu.gh 50 Variable PTB Prevalence HIV Prevalence Presumptive TB cases (N=195) Respondents who produced sputum (N=149) *Respondents with TB (N=5) *Pearson χ2 HIV screened participants (N=189) *HIV prevalence *Pearson χ2 N (%) N (%) N (%) (P-value) N (%) N (%) (P-value) Occupation before incarceration Formal 30 (15.4) 26 (17.4) 0 (0) χ2=1.37 30 (15.9) 0 (0) χ2=2.58 Informal 137 (70.2) 99 (66.4) 5 (p= 0.242) 137 (72.5) 11 (8.0) (p=0.108) Not employed 28 (14.4) 24 (16.1) 0 (0) 22 (11.6) 0 (0) Religion Christian 156 (80.0) 118 (79.2) 3 (2.5) χ2=1..6 152 (80.4) 10 (6.6) χ2=0.823 Muslim 38 (19.5) 31 (20.8) 2 (6.5) (p= 0.282) 36 (19.1) 1 (2.8) (p=0.661) Traditionalist 1 (0.5) 0 (0) 0 (0) 1 (0.5) 0 (0) Ethnicity Akan 72 (36.9) 51 (34.2) 1 χ2=4.58 70 (37.9) 3 (4.2) χ2=8.03 Ga/Dangme 35 (17.9) 25 (16.8) 0 (0) (p= 0.333) 34 (18.0) 1 (2.9) (p=0.090) Ewe 46 (23.6) 9 (6.0) 1 45 (23.8) 1 (2.2) Hausa 14 (7.2) 39 (26.2) 1 13 (69) 2 (15.4) Other 28 (14.4) 25 (16.8) 2 27 (14.3) 4 (14.8) Nationality Ghanaian 175 (89.7) 135 (90.6) 3 (2.2) χ2=10.59 169 (89.4) 7 (4.1) χ2=12.19 Nigerian 5 (2.6) 2 (1.3) 0 (0) **(p=0.014) 5 (2.6) 1(0.2) **(p=0.007) Malian 4 (2.1) 3 (2.0) 1 (33.3) 4 (2.1) 0 (0) University of Ghana http://ugspace.ug.edu.gh 51 Variable PTB Prevalence HIV Prevalence Presumptive TB cases (N=195) Respondents who produced sputum (N=149) *Respondents with TB (N=5) *Pearson χ2 HIV screened participants (N=189) *HIV prevalence *Pearson χ2 N (%) N (%) N (%) (P-value) N (%) N (%) (P-value) Other 11 (5.6) 9 (6.0) 1 (11.1) 1 (11.1) 3 (27.3) Smoking Yes 93 (47.7) 70 3 (4.3) χ2=0.35 92 (48.7) 2 (2.2) - No 102 (52.3) 79 2 (2.5) (p=0.553) 97 (51.3) 9 (9.3) Duration of smoke <10 46 (49.5) 41 (27.5) 0 χ2=2.8 10-19 28 (30.1) 32 (21.5) 2 (0.4) (p=0.246) >20 19 (20.4) 20 (13.4) 1 (0.2) Don’t smoke 102 ( - ) - - - - - *Prevalence, Pearson χ2 and P-values are for the Screened Presumptive TB cases and HIV screened participants; ** significant p-value <0.05 University of Ghana http://ugspace.ug.edu.gh 52 4.4 Prison related characteristics of presumptive PTB cases The average number of prisoners in the prison was 3527 during the study period comprising of; 3454 in male prison and 73 in female prison. Of the 195 study participants, 172 were from the male prison that constitutes about 5% of the total male prisoners, whilst 23 were from the female prison constituting 31.5% of the total female population as shown in table 3. About 66% of prisoners shared a cell with more than 20 inmates whilst those that share with less than 10 inmates were about 16% with a mean of 31 inmates per cell. When asked about history of incarceration only about 9% had been into prison before whilst 91% are serving their first imprisonment and of those who have history of imprisonment about only about 1.5% spent more than two years in the prison. Presumptive TB cases were distributed into four main categories according to their jail term and cell occupancy. Of the four categories, convicts (77.5%) were in the majority, constituting more than two-third of the prison population followed by the remand/trail (11.8%), life/high (5.6%) and condemned (5.1%) study participants. There was no significant difference among the category of imprisonment as all the positive cases were coming from the convict cells. Regarding the duration of stay in custody, 62.6% have spent 5 years or less in the prisons. The mean duration of sentence served was 5 years (SD +/-5) as shown in Table 3. All screened participants had permission to move out of cell to a yard within the block as in the case of condemned prisoners or to the general yard from 6:30 am to 5pm on a daily basis with a break during midday for counting of inmates. Those who were involved in labor outside the prison also have permission to leave the prison on a daily basis whilst those who were referred for medical care or due court do so with permission and escort. University of Ghana http://ugspace.ug.edu.gh 53 Table 3: Prison related characteristics with presumptive PTB cases Variable Presumptive TB cases (N=195) Respondents who produced sputum (N =149) *Respondents with TB prevalence N=5 (%) *Pearson χ2 (p-value) Prisoners in cell <10 31 (15.9) 25 (16.8) 0 χ2=1.08 10-20 35 (18.0) 29 (19.5) 1 (3.4) (p=0.582) >20 129 (66.1) 95 (63.7) 4 (4.2) Previous incarceration Yes 18 (9.2) 14 (9.4) 1 (7.1) χ2=0.68 No 177 (90.8) 135 (90.6) 4 (3.0) (p=0.408) Previous sentence (years) <2 10 (5.1) 7 (4.7) 1 (14.2) χ2=0.32 >2 3 (1.5) 2 (1.3) 0 (p=0.571) None 182 (93.3) 140 (94.0) 4 (2.9) Imprisonment category Remand/Trial 23 (11.8) 13 (87) 0 χ2=1.42 Life/High 11 (5.6) 11 (7.4) 0 (p=0.702) Condemned 10 (5.1) 8 (5.4) 0 Convict 151 (77.5) 117 (78.5) 5 (4.3) Sentence served (years) <5 122 (62.6) 85 (57.0) 3 (3.5) χ2=0.894 5-10 50 (25.6) 44 (29.5) 2 (4.5) (p=0.827) 10-20 15 (7.7) 12 (8.1) 0 >20 8 (4.1) 8 (5.4) 0 *Prevalence, Pearson χ2 and P-values are for the Presumptive TB cases 4.5 Morbidity related characteristics of presumptive PTB cases In this study about 52% of presumptive PTB cases reported with less than 5 symptoms whilst (48%) reported having more than 5 symptoms. More than 80% of the suspected cases indicated they developed the symptoms whilst they were in prison custody. Cough 191 (98%) was the leading symptom among participants followed by night sweats (85.6%), chest pains 158 (81%), weight loss (70.8%) and fever (64.6%). Most of those who reported with symptoms (78.8%) University of Ghana http://ugspace.ug.edu.gh 54 claimed they did not receive any treatment for the symptoms (see fig 5). In this study, 191 (98%) had cough with 108 (56.5%) and 68 (35.6%) having cough of 2-8 weeks and >8 weeks respectively. The mean cough duration was 4 weeks (SD+/- 1). One hundred and sixty (83.8%) of the prisoners developed symptoms during imprisonment of which 24 (15%) had received treatment. One hundred and fifty-seven (80.5%) had family history of PTB whilst 38 (19.5%) either had no history or were unable to recall history. 79 (40.5%) had history of contact with a TB case and 116 (59.5%) who were without history of TB contact. One hundred and sixty-two (83.1%) participants reported to have shared a cell with a chronically coughing inmate. With regards weight loss since onset of cough 138 (70.8%) confirmed that whilst 57 (29.2%) agreed with no weight change. When asked about their HIV status 14 (5.8%) said they had been previously screened for HIV whilst 181 (94.2%) said otherwise and it is significantly associated with TB (p<0.001). 27 (13.9%) had history of TB of which 24 (88.9%) received treatment during incarceration and 3 were before incarceration and agreed that they competed the complete therapy. BCG scar was present on 123 (63.1%) of study participants, see Table 4 below. Table 4: Morbidity related characteristics of presumptive PTB cases Variable Presumptive PTB (N=195) Respondents who produced sputum (N =149) *Respondents with TB prevalence N (%) *Pearson χ2 (p-value) History of cough Yes 191 (97.9) 147 (98.7) 5 (3.4) χ2=0.07 No 4 (2.1) 2 (1.3) 0 (p=0.791) Onset of cough Before incarceration 35 (17.3) 30 (20.1) 2 (6.7) χ2=1.22 (p=0.269) During incarceration 160 (82.72) 117 (78.5) 3 (2.6) Duration of cough University of Ghana http://ugspace.ug.edu.gh 55 Variable Presumptive PTB (N=195) Respondents who produced sputum (N =149) *Respondents with TB prevalence N (%) *Pearson χ2 (p-value) <2 15 (7.9) 13 (8.7) 0 χ2=4.05 2-8 108 (56.5) 81 (54.4) 1 (1.2) (p=0.132) >8 68 (35.6) 55 (36.9) 4 (7.3) Family history Yes 157 (80.5) 117 (78.5) 2 (1.7) χ2=1.05 No 38 (19.5 32 (21.5) 3 (14.3) (p=0.305) Contact history Yes 79 (40.5) 69 (46.3) 3 (4.3) χ2=0.39 No 116 (59.5) 80 (53.7) 2 (7.5) (p=0.532) Other prisoners coughing Yes 162 (83.1) 122 (81.9) 4 (3.3) χ2=0.01 No 33 (16.9) 27 (18.1) 1 (3.8) (p=0.912) Weight reduction Yes 138 (70.8) 47 (31.5) 2 (4.3) χ2=0.171 No 57 (29.2) 102 (68.5) 3 (2.9) (p=0.679) HIV status Yes 14 (5.8) 8 (5.4) 2 (25) χ2=11.61 No 181 (94.18) 135 (90.6) 3 (2.2) (p<0.001) Ever diagnosed TB Yes 27 (13.9) 25 (16.8) 1 (4) χ2=0.04 No 168 (86.1) 124 (83.2) 4 (3.2) (p=0.845) BCG vaccinated Yes 123 (63.1) 92 (61.7) 4 (4.3) χ2=0.73 No 72 (36.9) 57 (38.3) 1 (1.8) (p<0.393) *Prevalence, Pearson χ2 and P-values are for the Presumptive TB cases University of Ghana http://ugspace.ug.edu.gh 56 Figure 5: Distribution of TB symptoms among Presumptive, Screened and confirmed PTB cases 4.6 Prevalence of TB and HIV Co- infection among inmates of Nsawam Medium Security Prisons The co-infection prevalence was 1.3% among TB suspects or 40% among TB cases (Table 5). All 149 TB suspected cases screened for TB consented to be screened for HIV and were screened before the outcome of the TB results. Among the 5 confirmed PTB confirmed cases 2(40%) tested positive for HIV infection. The proportion of HIV positive among confirmed TB cases was very high compared to that of the presumptive TB cases (1.3%). The prevalence of TB and HIV co- infection was evenly distributed among both sexes with females having a higher prevalence than males (5.3%) and (0.8%) respectively, however upon univariate analysis there was an increased odds [OR=7.17, 95% CI =0.43- 119.67] of having co- infection among females compared to male counterpart but it was statistically insignificant as the multivariate analysis showed no difference. Also the 2 cases of co-infection were both separated, which had no univariate or bivariate difference as they fall within the same category but had a significant association with co-infection (p=0.042). 2.1 3.4 3.2 4.3 2.5 3.3 3.9 64.4 98.7 84.6 31.5 53.7 80.5 51.7 64.6 97.9 85.6 70.8 53.3 81 48.2 0 100 Fever Cough Nigh sweat Weight loss Appetite loss Chest pains Difficulty breathing Percentage (%) Presumptive Screened Cases University of Ghana http://ugspace.ug.edu.gh 57 TB and HIV co-infection was found to be among Ghanaian and Kenyan nationals making Nationality a significant risk factor for co-infection (p= 0.044) with Hausa ethnic group having a higher risk of co-infection than that of the Swahili [OR=3, 95%CI=0.17- 53.71], however upon multivariate analysis there was no difference of contracting co-infection among the ethnic groups and taking into account that majority of the inmates were Ghanaians. However age, sex occupation, education level and religion were not statistically significant with contracting TB and HIV co- infection. The two cases had at-least basic education and were employed in the informal sector with religion having equal representation of cases. Table 5: TB and HIV Co-infection and socio-demographic characteristics Variable Presumptiv e Co- infection participant s (N=149) N (%) Co- infection prevalence (N=2 or 1.3%) N (%) Crude OR (95% CI Adjus ted OR (95% CI) Fisher’s exact (P-value) Sex Male 130 (87.2) 1 (0.8) 1 1 (p=0.240) Female 19 (12.8) 1 (5.3) 7.17 (0.43- 1 Age <25 9(6.0) 1 1 1 25 – 34 44 (29.5) 1 (2.3) 0.98 (0.06-16.13) 1 (p=0.588) 35 – 44 43 (28.9) 1 (2.3) 1 1 >45 51 (34.2) 1 1 Marital status Married 71 (47.7) 1 1 **(p=0.042) Divorced, separated and widowed 31 (20.8) 2 (6.5) 1 Single 47 (31.5) 1 1 Education level None 29 (19.7) 1 1 (p=0.405) Basic 57 (60.6) 2 (3.5) 1 1 Secondary 57 (15.7) 1 1 Higher 6 (4.0) 1 1 Occupation before incarceration Formal 26(17.5) 1 (p= 1) University of Ghana http://ugspace.ug.edu.gh 58 Variable Presumptiv e Co- infection participant s (N=149) N (%) Co- infection prevalence (N=2 or 1.3%) N (%) Crude OR (95% CI Adjus ted OR (95% CI) Fisher’s exact (P-value) Informal 99 (66.4) 2 (2.0) 1 Unemployed 24 (16.1) 1 Religion Christian 118 (79.2) 1(3.2) 1 (p= 0.374) Muslim 31 (20.8) 1(0.8) 3.90 (0.24-64.18) Ethnicity Akan 51 (34.2) 1 **(p=0.044) Ga/Dangme 25 (16.8) 1 Ewe 39 (26.2) 1 Hausa 9 (6.0) 1 (11.1) 3 (0.17- 53.71) Other 25 (16.8) 1 (4.0) 1 *Prevalence, Fisher’s exact test P-values are for TB and HIV presumptive co-infection participants; ** P≤ 0.05 (significant level) 4.7 Association of HIV and risk factors This study did not find any association between risk factors of social habits/life style and HIV however not sharing sharps has a higher (72%) protection against HIV than those who were sharing sharps (OR =0.23: CI=0.23-2.25) and after adjusting for confounders (AOR=0.28; CI= 0.03-3.04), whilst those not using condoms has 52% less chance of contracting HIV than those who were using condoms ( OR=0.48; CI=0.14-1.65) and (AOR=0.47; CI=0.13-1.70) however this was not statistically significant with the infection of HIV (Table 6). Table 6: Association of HIV and risk factors Variable Presumptive PTB cases (N=195) HIV screened participants (N =189) HIV cases N (%) Fisher’s exact (P-value) Served sentence <5 122 (62.6) 117 (61.9) 8 (6.8) (p=0.933) 6-10 50 (25.64) 49 (25.9) 3 (6.1) University of Ghana http://ugspace.ug.edu.gh 59 10-20 15 (7.7) 15 (10.1) 0 (0) >20 8 (4.1) 8 (4.2) 0 (0) Sharing sharps Yes 5 (2.6) 5 (2.6) 1 (20) (p=0.262) No 190 (97.4) 184 (97.4) 10 (5.4) Condom use Yes 56 (28.7) 56 (29.6) 5 (8.9) (p=0.196) No 139 (71.3) 133 (70.4) 6 (4.5) Intravenous drug use Yes 2 (1.0) 2 (1.1) 0 (0) (p=0.887) No 193 (99) 187 (98.9) 11 (5.9) Previously incarcerated Yes 18 (9.2) 18 (9.5) 2 (11.1) (p=0.282) No 177 (90.8) 171 (90.5) 9 (5.3) Previous sentence (years) <=2 10 (5.1) 9 (4.8) 1 (11.1) (p=0.769) >2 3 (1.5) 3 (1.6) 0 (0) None 182 (93.3) 1 (0.5) 0 (0) Imprisonment category Remand/Trial 23 (11.8) 13 3 (23.1) (p=0.535) Life/High 11 (576) 11 0 (0) Condemned 10 (5,1) 8 1 (12.5) Convict 151 (77.4) 117 7 (6.0) University of Ghana http://ugspace.ug.edu.gh 60 4.8 Bivariate and Multiple Logistic Regression Analyses of PTB Risk Factors The significant level was set at 0.05 to select the variables for the multivariate analysis. Even though HIV and BCG scar were the only variables found to have a p-value less than the significant level (0.05), variables according to literature that are known to have strong association with PTB were also selected for the regression model as shown in Table 7. Occupation, ethnicity, nationality, imprisonment category, religion were dropped because they had more than 2 categories and cases were not proportionally spread among all the categories. Table 5 below shows the detail of the regression analyses. Among the 149 presumptive TB cases, who produced sputum, a total of 5 (3.4%) were identified as PTB based on GeneXpert analysis. Of this 5, two were diagnosed as very low, 1 medium and 2 very high bacterial load with no resistance detected. Results of analysis of the association between socio-demographic and other selected variables with PTB are summarized in table 7. Of the 149 suspects, 130 were males with 4(3.1%) PTB positive whilst 1(5.3%) of 19 females was PTB positive. Three (6.7%) of PTB were between 25-34 years with 2(2.8%) and 2(9.5%) PTB positive were married and single respectively. Four (4.5%) of PTB positives has at least basic education with all 5 being employed in the informal sector and 3(2.5%) were Christians. University of Ghana http://ugspace.ug.edu.gh 61 Table 7: Factors associated with PTB among Presumptive PTB cases Variable Respondents who produced sputum (N=149 N (%)) OR (95% CI) AOR (95% CI) (p-value) Sex Male 130 (87.2) 1 1 p=0.224 Female 19 (12.8) 1.75 (0.19-16.5) 1 Age <25 9 (6.0) 1 1 - 25 – 34 45 (30.2) 3.42 (0.34-34.10) 1 35 - 44 44 (29.5) 1.14 (0.07-18.77) 1 >45 51 (34.3) 1 1 Marital status Married 71 (47.7) 1 1 p=0.206 Divorced, separated and widowed 57 (38.3) 0.62 (0.005-6.97) 2.34 (0.06- 90.08) Single 21 (14.0) 3.63 (0.48-27.50) 1 Duration of smoke <10 13 (8.7) 1 1 10-19 81 (54.4) 1.09 (0.09-13.31) 1 >20 55 (36.9) 1 1 BCG vaccinated Yes 92 (61.7) 1 1 p=0.224 No 56 (37.6) 0.4 (0.04-3.67) 1.19 (0.10- 13.80) Unsure 1 (0.7) 1 Sentence served (years) <5 85 (57.0) 1 1 p=0.2445 University of Ghana http://ugspace.ug.edu.gh 62 5-10 44 (29.5) 1.3 (0.21-8.09) 1.10 (0.029- 42.56) 10-20 12 (8.1) 1 1 >20 8 (5.4) 1 - Prisoners in cell <10 25 (16.8) 1 1 p=0.224 10-20 29 (19.5) 0.81 (0.02-0.12) 1 >20 95 (63.7) 1 1 HIV status Yes 8 (5.4) 1 - p=0.224 No 135 (90.6) 14.67 (2.05-104.89) 1 No. of symptoms <2 11 (7.4) 1 1 p=0.224 3-4 37 (24.8) 0.28 (0.02-4.85) 1 5-7 101 (67.8) 0.31 (0.01-0.78) 1 HIV status Yes 8 (5.4) 1 1 p=0.224 No 135 (90.6) 14.67 (2.05-104.89) 1 No. of symptoms <2 11 (7.4) 1 1 p=0.224 3-4 37 (24.8) 0.28 (0.02-4.85) 1 5-7 101 (67.8) 0.31 (0.01-0.78) 1 University of Ghana http://ugspace.ug.edu.gh 64 4.9 Risk Factors association with PTB 4.9.1 Socio-demographic factors associated with PTB On logistic regression analysis there was no significant association between the socio-demographic variables and PTB (Table 7). However the odds of having PTB among female suspects was higher (OR =1.75, 95% CI= 0.19-16.5) than with males, and the age group 25-34 years significantly increases risk of having PTB (OR=3.42, 95% CI=0.34-34.10) compared to those less than 25 years or higher than 45 years. The odds of having PTB among singles is significantly higher (OR=3.63, 95% CI=0.48-27.50] than those who are married whilst that of divorced or separated or widowed after adjusting for confounders has more than two times higher risk of PTB infection (AOR=2.34, 95%CI=0.06-90.08) compared with that of the married or single group. Consequently being a smoker for 10 years or more has an increased (OR=1.09, 95%CI=0.09-13.31) risk of PTB infection however after adjusting for cofounders there was no difference between the number of years. Nonetheless all of the above associations were statistically insignificant. 4.9.2 Prison related factors Four out of five PTB cases had no prior history of incarceration and upon bivariate analysis no history of incarceration has a significantly higher [OR =0.40, 95% CI= 0.04-3.82] protection against PTB than those with history but the association became indifferent after adjusting for confounders between those with history and those without history of incarceration as in Table 7. Subsequently at bivariate analysis there was a protective association between PTB and number of prisoners per cell (OR = 0.81, 95% CI =0.02-7.12) showing that having 10-20 prisoners per cell reduce the risk of PTB and upon adjusting for confounders there was no significant difference among the number of prisoners per cell in contracting PTB as in table 7. University of Ghana http://ugspace.ug.edu.gh 65 Prisoners who have stayed in the prison between 6-10 years have an increased risk of contracting PTB than those who have stayed for 5 years or less [OR=1.30, 95%CI=0.21-8.09] and after adjusting for confounders it was still a higher risk factor for contracting PTB infection (AOR=1.10, 95% CI=0.03-42.56). However none of the prison associated factors were statistically significant with the associated outcome as shown in table 7. 4.9.3 Morbidity related factors associated with PTB Inmates without BCG scar was found to have protection against PTB in contrast with those with scar (OR=0.4, 95% CI=0.04-3.67) and after adjusting for confounder it became an increased risk of contracting PTB (AOR=1.19, CI=0.10-13.80] than those with the scar but it was statistically insignificant as illustrated in table 7. Also prisoners without history of PTB have a higher protection against PTB than those with history of PTB [OR=0.85 95% CI=0.09-7.91] and after multivariate analysis there was no difference with contracting TB among those with history of TB and those without a history of TB and they were both statistically insignificant as shown in table 7 above. University of Ghana http://ugspace.ug.edu.gh 66 CHAPTER FIVE DISCUSSION This chapter relates the findings of the study done in Nsawam Medium Security Prisons in Nsawam with that of studies done on the related topic around the universe as reviewed in the literature. Studies have reported prevalence of TB, HIV and other blood borne diseases to be very high among prisoners than that of national averages (USAID, 2013; Baussano et al., 2010; Reid et al., 2012; Kazi, Shah, & Jenkins, 2010). This study determined the prevalence of PTB, HIV and co-infection of TB and HIV and its associated risk factors among prisoners in Nsawam Medium Security Prison. 5.1 Background of inmates In the current study most of the study participants were males, with a female to male ratio of 1:8. More than two-third of them were between the ages of 17-44 years which comprise of the economically productive group; almost half of the population have at least basic education and majority of them were employed in the informal sector. These background shows that majority of the prisoners were coming from a low socio-economic segment of the population who are likely to have undiagnosed disease conditions exposing them to several infectious diseases. This finding is similar to studies done in South Africa (Telisinghe et al., 2014), India (Dolan & Larney, 2010) and Ethiopia (Ali et al., 2015) which showed that high and low income countries prison population represents a poorly educated and socially marginalized and low income group of people from the general population. University of Ghana http://ugspace.ug.edu.gh 67 5.2 Prevalence of PTB The overall prevalence of PTB in prison was 3.1% (8/258) or 3101 per 100,000 prison population. The prevalence in this study is about eleven times higher than the prevalence in the general population which was last measured in 2014 to be 286 per 100,000 (p<0.001) (WHO, 2015). This high burden may be attributed to the aggressive transmission of TB in the prison as reported in Zambia and South Africa since most of the cases might go undiagnosed or have delayed diagnosis and treatment of which the infection would have been vastly spread among inmates (Henostroza et al., 2013; Telisinghe et al., 2014) as there were 3 inmates currently on treatment at the time of the study. Several studies have reported higher prevalence of PTB among prisoners than in the general population (Baussano et al., 2010; USAID, 2013). Similar studies in Malawi and Zambia found a prevalence that was ten times higher than that of the general population (Banda, Gausi, Harries, & Salaniponi, 2009; Henostroza et al., 2013). Also similar studies done in prisons of developed countries in Europe experienced higher prevalence of TB among prisoners compared to that of the general population (Aerts, Hauer, Wanlin, & Veen, 2006). The percentage of PTB in this study is lower than that of the Zambian study (4005/100,000) (Henostroza et al., 2013) but higher than that found in a study done in Thailand (354.8/100,000) (Jittimanee, Ngamtrairai, White, & Jittimanee, 2007) and that found in Ethiopia (1913/100,000) (Abebe et al., 2011). Irrespective of the difference in study design, methods, individual backgrounds and country, most of the studies so far has shown a high prevalence of TB among prison population. On the contrary, a study done in the Volta Region of Ghana reported a much lower prevalence of TB among prison population (514 per 100,000) compared to this study. However, this could be University of Ghana http://ugspace.ug.edu.gh 68 attributed to the lower sensitivity of the screening tool employed which used smear microscopy unlike that of the GeneXpert used in this study (Kwabla, Ameme, & Nortey, 2015). An Observational study carried out with inmates of a prison and a jail in the State of Sao Paulo, Southeastern Brazil, which used Tuberculin skin testing and sputum smear examination, sputum culture and drug susceptibility testing found that of the 2,237 (91.9%) who agreed to submit to tuberculin skin testing 73.0% had positive reactions giving TB prevalence of 830.6 per 100,000 inmates a value 21.4 times higher than the Brazilian national prevalence. (Nogueira, Abrahão, & Galesi, 2012) The high prevalence of TB recorded in this study can be attributed to the population size of Nsawam Medium Security Prison, the sensitivity of the test used and also the low number of inmates that were involved in the study. 5.3 Prevalence of HIV Among the 189 study participants that consented to be screened for HIV, this study found a higher prevalence of 5.8% (11/189) HIV infection among study participants in Nsawam Medium Security Prison as compared to the National prevalence of 1.8% (p<0.001) (MoH, 2016a). This is very similar to a national study conducted among prison inmates and officers in Ghana which found a prevalence of 5.9% among inmates (A. A. Adjei et al., 2008) with a 0.1% decrease in the HIV infection among inmates. This decease may be attributed to the significant efforts of the Plan Parenthood Association of Ghana (PPAG) in partnership with the NACP to help screen inmates for HIV infection as well as having inmates as peer educators of HIV to help control the transmission of the disease. University of Ghana http://ugspace.ug.edu.gh 69 The HIV prevalence in presumptive TB cases recorded in this study is higher than the 4.4% and 2.3% found among presumptive TB cases in Ethiopia (Ali et al., 2015) Pakistan (Manzoor et al., 2009) respectively but lower than the 7.6% found in another Ethiopian study in North Gondar prison (Moges et al., 2012). Despite the different diagnostic tools used, it is evident that the prevalence of HIV among prisoners is higher than that seen in the general population irrespective of the country and individual background of inmates. This is evident in two studies done in Ethiopia where serology was used in both cases to diagnose HIV among inmates with a prevalence of 2.0% (95% CI 0.6–3.4%) (Wondimeneh et al., 2012) in one and 7.6% (Moges et al., 2012) in the other. 5.4 Prevalence of TB and HIV co-infection The prevalence of TB and HIV co-infection among prisoners has been well documented (Health, 2007; Awofeso, 2010). This situation presents a major challenge in the diagnosis and management of the condition to the prison health system. In the current study, out of 189 presumptive TB cases that consented to be screened for HIV, a total of 11(5.8%) tested positive for HIV among which 2 (18.2%) had TB co-infection. The prevalence of HIV infection in the GeneXpert screened presumptive TB cases was calculated to be 1.3%. This prevalence is four times higher than that of the national prevalence of TB and HIV co-infection which is 282 per 100,000 (WHO, 2015) and significantly differs from that of the national prevalence (p=0.0071), even though the diagnostic tool used was rapid diagnostic and not confirmatory and requires a much better and confirmatory diagnostic tool which might give a prevalence higher than that observed in the study. University of Ghana http://ugspace.ug.edu.gh 70 The prevalence of TB and HIV co-infection in this study is lower than the 25% ( 95% CI=10-47) found in a Cameroonian study even though the diagnostic method was the same (Noeske et al., 2006) and of that found in a retrospective study done in a Uganda prison which found out that 57% of TB patients were co-infected with HIV (Schwitters et al., 2014) 5.5 Risks factors associated with PTB among inmates Tuberculosis infection is endemic in resource poor countries and countries with high rate of HIV infection. Factors that have been associated with its infection in similar studies include; age, sex, illiteracy, low socio economic status, smoking, co-morbid conditions such as burden of HIV, previous history of PTB, overcrowding, inadequate ventilation, length of stay in prison, history of incarceration, sharing a cell with a chronically coughing inmates, cough, fever and chest pain (Lobacheva, Asikainen, & Giesecke., 2007; Adjei et al., 2008). In this study, HIV was significantly associated with PTB infection. This is in accordance with findings of (Moges et al., 2012; Telisinghe et al., 2014) in which HIV among PTB inmates was found to be significantly associated with PTB infection. The five PTB confirmed cases in the study was found to be four males and one female which is consistent with results from other studies (Dara et al., 2015; Kuhleis et al., 2012; Kwabla et al., 2015). This is possible because of the population ratio of male to female in the current study which is equivalent to one female is to forty-seven males in terms of the distribution. Similarly findings observed by Kwabla et al (2015) showed that out of 389 prisoners screened for PTB, 370 were males forming 95% of the prison study population. However this was not significantly associated with PTB even though the study found that females have double higher risk of contracting PTB than males which is in line with that found with similar study Kwabla et al., (2015) and might be University of Ghana http://ugspace.ug.edu.gh 71 due to the smaller number of study participants compared to other studies which used a very large number. However in this study age, illiteracy, overcrowding, smoking, previous history of PTB, length of stay in prison, history of incarceration, sharing a cell with a chronically coughing inmates, cough, fever and chest pain were not significantly associated with PTB infection. Although this study found PTB to be predominant between the age of 25 and 44 years it was not significantly associated with PTB infection which is similar to that found by Abebe et al., (2011). In this study, 4 of the 5 positive cases were sharing a cell with a chronically coughing inmate but this was also not significantly associated to PTB infection contrary to that found with Abebe et al. (2011) which showed a horizontal pattern (person –to-person) of transmission. Although this study did not find this to be significantly associated with TB infection, horizontal pattern of spread must be prevented to avoid the spread and increase in the number of PTB infections among inmates. 5.6 Risk Factors associated with HIV among inmates HIV infection among inmates is a global burden and cuts across all nations. Factors that have been associated with its infection in similar studies include; age, sex, illiteracy, unmarried, history of sharing sharps, condom use and intravenous drug use and length of stay in prison. This study found out that sex was significantly associated with HIV infections as 9 out of 11 (81.8%) HIV positive participants were females (p<0.001) as compared to the (18.2%) males. This is in accordance with the findings of Adjei et al., (2008) which documented that female gender is significantly associated with HIV infection. This study did not find any significant association of age with HIV infection. However majority (72.7%) of the cases were between 17 and 44 years and showed an increased risk of contracting University of Ghana http://ugspace.ug.edu.gh 72 the infection which is consistent with what was found by Adjei et al., (2008) that age between 17 and 46 is significantly associated with HIV infection. Even though this study did not find it statistically significant it must not be ignored as this is the young and sexually active age group when people are exploring their youthfulness and thus an intervention will help in the reduction in the spread of the disease. In this study marital status was also significantly associated with HIV infection, due to the high (54.5%) of the HIV positive inmates been single which is associated with a higher risk of about 17 times than that of the married group in contracting the infection which is contrary to what was reported by Kazi et al., (2010) that being unmarried is not significantly associated with HIV infection and consistence with (Adjei et al., 2008) findings that being single is significantly associated with contracting HIV infection. This finding must be taken into consideration when targeting the control of the disease as it has been consistently associated with the risk of exposure in contracting HIV infection. 5.7 Limitation The study was a subjective method in sampling the inmates as only those who presented with cough and were willing to be part of the study were sampled whilst there is a possibility of inmates coughing but did not show up to be part of the study. It was unable to perform analysis among those who had short duration of cough, or who do not meet the screening criteria of the WHO screening tool, therefore the prevalence of PTB may have been underestimated, because reporting error (under-reporting) and cross-sectional nature of the study may have influenced the categorization of these prisoners into the short duration of cough group. University of Ghana http://ugspace.ug.edu.gh 73 Also, difficulty of getting productive sputum and adequate amount for the GeneXpert (i.e. 3-5 ml) making use of poor quality of sputum might have influenced the performance of the analysis. While the use of an alternative diagnostic tool like chest X-ray could have been the solution in the study. This may have also underestimated the actual prevalence of PTB. The low sample size used due to time and financial factors as an increase in sample size and additional diagnostic tools like chest X-ray and culture would have increased the prevalence than what have been reported already. Furthermore, esponses and study findings may have been compromised by the study design (i.e. cross sectional study) which allows for only temporality and point assessment, as well as the choice of study site (regional hospital) may have. The above limitations indicate possibility of confounder and selection bias. Hence, the result of the study should be interpreted with caution. University of Ghana http://ugspace.ug.edu.gh 74 CHAPTER SIX CONCLUSION AND RECOMMENDATION 6.1. Conclusion It is known that Tuberculosis and HIV infections are both serious infectious diseases in Ghana. Both diseases can result in increased morbidity and mortality among prisoners. This research therefore concludes that:  There is a high prevalence of PTB in Nsawam Medium Security Prison with possible active transmission of TB among inmates  There is a high prevalence of HIV in Nsawam Medium Security Prison with possible active transmission of HIV among inmates.  The prevalence of TB and HIV co-infection was found to be high.  HIV was found to be statistically significant associated risk factor for TB which is consistent with the high burden prevalence of TB and HIV in the country and marital status, gender and age was also found to be statistically significant associated risk factors for HIV. In summary, the high prevalence and associated risk factor for TB may favor an active transmission of TB, and put the prison population at increased risk of developing TB which could be also a great health threat to the surrounding community and nation as University of Ghana http://ugspace.ug.edu.gh 75 a whole. 6.2. Recommendation  There is the need to conduct active surveillance of TB to enable the identification of early infectious cases, prevent further delay in diagnosis and reduce prolonged transmission of TB in the prison.  Smear positive patients for the full initial phase of DOTS treatment should be segregated in prison and must be strengthened in prison TB control strategies.  Policy for all prisons to conduct admission screening among new prisoners with or without cough and enquiring about history of TB in order to identify early infectious cases, trace defaulters, and further reduce the transmission of TB and emergence of MDR-TB, during incarceration and upon discharge into the community should be put in place.  The prison health service should develop an information, education and communication (IEC) strategy that improves health seeking behavior and practice, and adherence to the treatment by inmates.  NTP and NACP should establish strong cooperation with the Prison authorities to develop locally appropriate interventions to reduce transmission, development of MDR TB and to aid the control of the diseases in the general population.  Conduct a prospective longitudinal study to estimate prevalence (incidence) and associated risk factors of TB. It will give an opportunity to address the dilemma of acceptable screening strategy and criteria for the prison TB control program by researchers and the NTP. University of Ghana http://ugspace.ug.edu.gh 76 REFERENCES Abebe, D. S., Bjune, G., Ameni, G., Biffa, D., & Abebe, F. (2011). Prevalence of pulmonary tuberculosis and associated risk factors in Eastern Ethiopian prisons. The International Journal of Tuberculosis and Lung Disease : The Official Journal of the International Union against Tuberculosis and Lung Disease, 15(5), 668–73. http://doi.org/10.5588/ijtld.10.0363 Addis, Z., Adem, E., Alemu ’, A., Birhan ’, W., Mathewos ’, B., Tachebele, B., & Takele, Y. (2015). Prevalence of smear positive pulmonary tuberculosis In Gondar prisoners, North West Ethiopia. AsianPacificjournal of Tropical Medicine, 8(2), 127–131. http://doi.org/10.1016/S1995-7645(14)60302-3 Adjei, A. a, Armah, H. B., Gbagbo, F., Ampofo, W. K., Boamah, I., Adu-Gyamfi, C., … Mensah, G. (2008). 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E., Almukhamedov, O., Pulatov, D., Vezhnina, N., Dooronbekova, A., & Zhussupov, B. (2014). Prevalence, Risk Factors and Social Context of Active Pulmonary Tuberculosis among Prison Inmates in Tajikistan. PLoS ONE, 9(1), e86046. http://doi.org/10.1371/journal.pone.0086046 Wondimeneh, Y., Muluye, D., & Belyhun, Y. (2012). Prevalence of Pulmonary tuberculosis and immunological profile of HIV co-infected patients in Northwest Ethiopia. BMC Research Notes, 5(1), 331. http://doi.org/10.1186/1756-0500-5-331 World life expectancy. (2015). World Health Rankings. Retrieved December 14, 2015, from www.worldlifexpentancy.com/causeofdeath/tuberculosis/bycountry University of Ghana http://ugspace.ug.edu.gh 84 APPENDICES Appendix 1: Consent form INFORMED CONSENT Dear respondent, We are asking you to take part in a research study on Prevalence of Pulmonary Tuberculosis among inmates of Nsawam medium security prisons. We want to be sure that you understand the purpose and your responsibilities in the research before you decide if you want to be in it. Please ask us to explain any word or information that you may not understand. This is a research study that would involve collection of sputum for detection of pulmonary tuberculosis using Genexpert to analyze the samples and minor discomfort due to needle prick for capillary blood sample will be experienced using a lancet as the lancet will pierce the skin of one of your fingers causing little pain for the diagnosis of HIV using First Response rapid diagnostic testing if you agree to do the HIV testing because it is optional. Participation in this research will not expose you to any physical, social or psychological risks. Participation in this research will be of benefit to you directly and to your fellow inmates as you will get to know your TB and HIV status if positive appropriate treatment will be made for further management as TB is treatable whilst HIV is manageable. It will also benefit other inmates and prison staff and implementation of new programs You are free to decide if you want to be in this research or not. University of Ghana http://ugspace.ug.edu.gh 85 We will protect information about you taking part in this research to the best of our ability. We will neither use your name in any reports nor discuss your participation with anyone outside the research team. No payments will be made for your participation. You may end your participation at any time with no negative consequence to you. If you have any questions about the research, call Frances M.T. Sesay on 0560566162 or email francesmtsesay@gmail.com This research has been reviewed and approved by the Ghana Health Service ethical review board and permission from the director of Ghana Prisons Services. If you have any questions about how you are being treated by the study or your rights as a participant you may contact Mrs. Hannah Frimpong 0244516482/ 0202920651. I understand all that has been explained to me about the study – objectives, benefits, risks and my rights, and I agree to participate in this study. / / Signature of respondent Date University of Ghana http://ugspace.ug.edu.gh 86 Appendix 2: Questionnaire Qtn No. Questions Response Participant ID: | | | | Section 1 Socio-demographic information 1 Sex 1. Male 2. Female | | 2 What is your age in years (i.e. age at last birthday)? | | | | years 3 What is the highest level of school you attended? 1. No education 2. Primary 3. Middle 4. JSS/JHS 5. Secondary/Vocational 6. SSS/SHS 7. Higher | | 4 What is your nationality? 5 What is your ethnicity? 1. Akan 2. Ga/Adangbe 3. Ewe 4. Hausa 5. Other, please specify …………………… | | 6 What is your religion? 1. Christian 2. Muslim 3. Traditionalist 4. Atheist 5. Other, please specify …………………… | | 7 What is your current marital status? 1. Married 2. Single 3. Divorced 4. Separated 5. Widowed | | University of Ghana http://ugspace.ug.edu.gh 87 Qtn No. Questions Response 8 What was your employment status before incarceration? 1. Unemployed 2. Employed If unemployed, go to Qtn 10 | | 9 If employed, what was your occupation, that is, what kind of work did you mainly do? Section 2 Tuberculosis Screening 10 Do you have history of fever? 1. Yes 2. No If no, go to Qtn 12 | | 11 If yes duration of fever? 1. More than 1 week 2. More than 2 weeks 3. More than 3 weeks 4. More than 4 weeks | | 12 Do you have history of cough? 1. Yes 2. No If no, go to Qtn 16 | | 13 If yes, duration of cough. 1. Less than 2 weeks 2. 2 weeks 3. 3 weeks 4. 4 weeks 5. 8 weeks 6. More than 8 weeks | | 14 Onset of cough: 1. Before incarceration 2. During incarceration | | 15 Do you produce sputum on coughing? 1. Yes 2. No | | 16 Do you sweat excessively at night? 1. Yes 2. No | | University of Ghana http://ugspace.ug.edu.gh 88 Qtn No. Questions Response 17 Have you noticed reduction in weight since incarceration? 1. Yes 2. No | | 18 Has your appetite reduced since incarceration? 1. Yes 2. No | | 19 Were you vaccinated with BCG? 1. Yes 2. No | | 20 Have you been previously Screened for TB: 1. Yes 2. No If no, go to Qtn 22 | | 21 If yes to question 20, by who? 22 Have you been diagnosed with TB before? 1. Yes 2. No | | 23 What is your weight? kg 24 What is your height? cm 25 Nutritional Status: BMI kg/m2 Section 3 Risk Factors 26 Do you have a family history of TB? 1. No 2. Yes 3. Don’t Know | | 27 Do you have history of contact with TB patient? 1. Yes 2. No 3. Don’t know | | 28 Are other prisoners coughing for more than 2 weeks in the cell? | | University of Ghana http://ugspace.ug.edu.gh 89 Qtn No. Questions Response 1. Yes 2. No 3. Don’t know 29 Have you been previously incarcerated? 1. Yes 2. No If no, go to Qtn 31 | | 30 If yes, duration of last incarceration: years, months, days 31 What is the duration of your current sentence? years, months, days 32 What is the duration of sentence you have served till today? years, months, days 33 How many prisoners are in your cell? 34 Are you sharing sharps? 1. Yes 2. No If no, go to Qtn 36 | | 35 If yes, type(s) of sharps: 1. Blade 2. Needle 3. Knife 4. Scissors 5. Others (Specify) ……………….. | | 36 What was your sexual preference before incarceration? 1. Anal Sex 2. Vaginal Sex 3. Bi-sexual | | 37 Were you using condom during sex before incarceration? 1. Yes 2. No | | University of Ghana http://ugspace.ug.edu.gh 90 Qtn No. Questions Response 38 Have you been previously screened for HIV? 1. Yes 2. No If yes, what was the outcome............................. | | Section 4 Social Habits/ Life Style 39 Were you consuming alcohol before incarceration? 1. Yes 2. No | | 40 Have you ever smoked? 1. Yes 2. No | | 41 Have you used drug intravenously? 1. Yes 2. No | | 42 VCCT 1. Positive 2. Negative | | 43 Are you experiencing chest pains? 1. Yes 2. No | | 44 Do you experience difficulty in breathing? 1. Yes 2. No | | 45 How long have you smoked before incarceration? University of Ghana http://ugspace.ug.edu.gh 91 Appendix 3: Laboratory Form Participant ID: | | | | Date of sputum sample collection: ………./………/……… Date sample received: ………/………/……… Date of sample processing: ………/………/……… Sample description: A. Salivary B. Bloody C. Mucopurulent GeneXpert result A. Mycobacterium tuberculosis DNA Present Absent B. RIF resistance Present Absent University of Ghana http://ugspace.ug.edu.gh 92 TB SCREENING QUESTIONNAIRE Appendix 4: WHO TB Screening Questionnaire NAME:..................................................................... AGE:........................... SEX: M/F DATE:................................................ SYMPTOM SCREEN Do you have any of the following symptoms? (Please circle grade for response) Yes No Cough more than 2 weeks 2 0 Cough less than 2 weeks 1 0 Sputum production 2 0 Coughing up blood 2 0 Loss of weight in last 3 months 1 0 Drenching night sweats 1 0 Fever 1 0 Chest pain 1 0 History of contact with a TB case History of smoking/Alcohol 1 0 Total Score: Consider Client as SUSPECT IF: Interpretation Cough is for 2 weeks or more Suspect Cough is less than 2 weeks & score 3 or more on symptom screen Suspect Score of 4 or more on symptom screen Suspect CONCLUSION (Circle) SUSPECT NON-SUSPECT REQUEST SPUTUM SMEAR MICROSCOPY FOR ALL SUSPECTS University of Ghana http://ugspace.ug.edu.gh 93 Appendix 5: Ghana Health Service Ethical Approval Certificate University of Ghana http://ugspace.ug.edu.gh 94 Appendix 6: Ghana Prisons Service Approval Letter University of Ghana http://ugspace.ug.edu.gh