ral
ssBioMed CentBMC Infectious Diseases
Open AcceResearch article
Seroprevalence of HHV-8, CMV, and EBV among the general 
population in Ghana, West Africa
Andrew A Adjei1, Henry B Armah*1, Foster Gbagbo1, Isaac Boamah2, 
Clement Adu-Gyamfi1 and Isaac Asare1
Address: 1Department of Pathology, University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana and 
2Department of Microbiology, University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
Email: Andrew A Adjei - andrewadjei50@hotmail.com; Henry B Armah* - hbaarmah@hotmail.com; 
Foster Gbagbo - fostergbagbo@yahoo.com; Isaac Boamah - ikebosa@yahoo.com; Clement Adu-Gyamfi - clementgascua@hotmail.com; 
Isaac Asare - isaacaasare@yahoo.com
* Corresponding author    
Abstract
Background: Human herpesvirus 8 (HHV-8), cytomegalovirus (CMV) and Epstein-Barr virus
(EBV) are prevalent in Africa, but less common elsewhere and the modes of transmission are still
subject to debate. Generally, they rarely cause disease in the immunocompetent host but are highly
oncogenic when associated with immunosuppression. Although the high prevalence of HHV-8,
CMV and EBV has been well documented in Africa, such data are sparse from Ghana.
Methods: Serum samples from 3275 HIV-seronegative healthy blood donors and 250 HIV-AIDS
patients were tested for antibodies specific for HHV-8, CMV and EBV by IgG ELISA assays.
Differences in seropositivity rates by gender and age were evaluated using the Chi-square test with
Yates correction.
Results: Of the 3275 HIV-seronegative healthy blood donors tested, 2573 (78.6%) were males and
702 (21.4%) were females, with ages ranging from 18 to 65 years (median 32.6; mean 31.2; mode
30). Of the 250 HIV-AIDS patients tested, 140 (56%) were males and 110 (44%) were females, with
ages ranging from 17 to 64 years (median 30.8; mean 30.3; mode 28). Among the HIV-seronegative
healthy blood donors, overall seroprevalence of HHV-8, CMV and EBV was 23.7%, 77.6% and
20.0%, respectively. Among the HIV-AIDS patients, overall seroprevalence of HHV-8, CMV and
EBV was 65.6%, 59.2% and 87.2%, respectively. The seroprevalence of HHV-8 (p < 0.005) and EBV
(p < 0.001) was statistically significantly higher in HIV-AIDS patients compared to HIV-seronegative
healthy blood donors. There was no statistically significant difference (p = 0.24) between CMV
seroprevalence in HIV-AIDS patients and HIV-seronegative healthy blood donors. Age and gender
were not independent determinants (p > 0.05) for all three infections among HIV-seronegative
healthy blood donors and HIV-AIDS patients in Ghana.
Conclusion: The results presented herein indicate that HHV-8, CMV and EBV infections are
hyperendemic in both HIV-seronegative and HIV-seropositive Ghanaians, and suggest primarily a
horizontal route of transmission of these three viral infections in Ghana.
Published: 18 August 2008
BMC Infectious Diseases 2008, 8:111 doi:10.1186/1471-2334-8-111
Received: 2 April 2008
Accepted: 18 August 2008
This article is available from: http://www.biomedcentral.com/1471-2334/8/111
© 2008 Adjei et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8
(page number not for citation purposes)
BMC Infectious Diseases 2008, 8:111 http://www.biomedcentral.com/1471-2334/8/111
Background
There are currently eight known human herpesviruses:
cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes
simplex virus 1, herpes simplex virus 2, human herpesvi-
rus 6, human herpesvirus 7, human herpesvirus 8 (HHV-
8), and varicella-zoster virus. All eight, except herpesvirus
6 and herpesvirus 7, are known to be pathogenic to
humans. HHV-8 is also known as Kaposi's sarcoma-asso-
ciated herpesvirus (KSHV). HHV-8, CMV, and EBV are
lymphotropic herpesviruses and responsible for a wide
variety of human diseases, caused either by primary infec-
tion or by reactivation under immunosuppressive condi-
tions. The majority (>90%) of the adult human
population carries asymptomatic infection of EBV and
CMV. Although HHV-8 shares substantial homology with
EBV, it has a marked lower (2–30%) seroprevalence rate
in the adult human population, with a specific tropism for
people of Mediterranean and sub-Sahara African coun-
tries [1-4]. HHV-8 and EBV are oncogenic viruses with a
long latency period in healthy hosts and will reactivate
from dormancy when the hosts are immunosuppressed.
Primary infections with these viruses in the immunocom-
petent host are generally asymptomatic. The neoplastic
potentials of these two viruses have been well established,
especially within the context of immunosuppressed
patients who are undergoing bone-marrow transplanta-
tion or are co-infected with the human immunodeficiency
virus (HIV) [5].
HHV-8 is a γ-herpesvirus that was discovered in 1994 in
Kaposi's sarcoma (KS) tissues from a patient with AIDS,
thereby establishing a link between HHV-8 infection and
the emergence of KS. HHV-8 is now considered to be the
etiological agent of all the clinico-epidemiological forms
of KS (including AIDS KS, classic KS, endemic KS, and
iatrogenic KS), primary effusion lymphoma, body cavity-
based lymphoma, and multicentric Castleman's disease.
Several studies show high prevalence rates of HHV-8 anti-
bodies among male homosexuals, African children, Bra-
zilian Amerindians, and elderly individuals in certain
regions of the Mediterranean basin [4]. Sexual transmis-
sion of HHV-8 might play an important role among high-
risk group populations, such as homosexual men in West-
ern countries. However, in endemic areas where HHV-8
seroprevalence is high during childhood and adolescence,
viral transmission might occur through nonsexual con-
tact. This is particularly evident in African populations
where high prevalence rates have been observed in infants
and children, with a HHV-8 seroprevalence similar to that
observed in adults [4].
CMV is a β-herpesvirus and known to be present in saliva,
cervical secretions, breast milk, semen, and human lym-
wide are 60 to 100%, possibly due to transmission
through breastfeeding, sexual contact and spread from
children [6,7]. Transfusion-transmitted CMV infection is a
significant cause of morbidity and mortality, particularly
in immunocompromised patients (including premature
low-birth-weight infants [<1500 g] born to CMV-seroneg-
ative mothers, CMV-seronegative recipients of autologous
or allogeneic bone marrow or peripheral blood stem cell
transplantation, CMV-seronegative solid-organ transplant
recipients, and CMV-seronegative patients with AIDS [8].
In all of these at-risk patients, it is appropriate to provide
"CMV-safe" blood for transfusion.
EBV was first discovered in 1964 in Burkitt lymphoma
(BL), a B-cell-derived tumor. EBV is ubiquitous in the
adult population worldwide, and establishes a life-long
persistent infection of B lymphocytes characterized by
virus shedding into saliva [9]. African children are
infected early in life and most have seroconverted by age
3 years, while in affluent countries, primary infection is
delayed until young adult life [10]. EBV is now considered
to be etiologically associated with endemic Burkitt's lym-
phoma (BL), nasopharyngeal carcinoma, classical Hodg-
kin's lymphoma (HL) and extranodal nasal NK/T-cell
lymphoma. EBV is transmitted via saliva in an oral-fecal
route of transmission, and it infects B lymphocytes as well
as certain epithelial cells.
In a recent review of 28 HHV-8 seroepidemiologic studies
of adult populations from 16 African countries reported
between 1996 and 2002, most African countries (namely
Botswana, Cameroon, Democratic Republic of Congo,
Egypt, Gambia, Ghana, Ivory Coast, Nigeria, South Africa,
Tanzania, Uganda, Zambia, and Zimbabwe) had high
seroprevalence rates ranging from 26% to 86%, with the
exception of Central African Republic, Eritrea and Senegal
which had relatively lower (up to 25%) seroprevalence
rates [11]. Another recent review of 7 HHV-8 seroepidemi-
ologic studies of pediatric populations from 7 African
countries reported between 1998 and 2003 showed high
seroprevalence rates ranging from 30% to 58.1% in most
African countries (namely Cameroon, Egypt, Ghana, Tan-
zania, Uganda, and Zambia), with the exception of Eritrea
which had a very low (up to 2%) seroprevalence rate [4].
Although Kaposi's sarcoma is common in Ghana com-
pared to other cutaneous malignancies [12], data on the
seroprevalence of HHV-8 in Ghana are scanty. Ablashi
and colleagues first reported a HHV-8 seroprevalence rate
of 41.9% in healthy Ghanaians aged 13–72 years in 1999
[3]. Subsequently, Nuvor and colleagues reported statisti-
cally significant (p < 0.05) difference in HHV-8 seroprev-
alence rate between HIV-seronegative healthy blood
donors (32.3%) and asymptomatic HIV-seropositive indi-Page 2 of 8
(page number not for citation purposes)
phocytes. CMV is an ubiquitous agent, and seropositivity
rates in the adult population over 40 years of age world-
viduals (45.5%) in Ghana [13]. Data on the prevalence of
CMV and EBV infections in Ghana are even scantier. The
BMC Infectious Diseases 2008, 8:111 http://www.biomedcentral.com/1471-2334/8/111
reported seroprevalence rate of CMV among healthy Gha-
naian blood donors aged 18–60 years was 93.2% [14].
EBV viral DNA was detected in plasma samples of 40%
(47% in the malaria-infected and 34% in the non-malaria
group) of Ghanaian children aged 6 months to 12 years
[15]. The aim of this study was to determine and compare
the seroprevalence of HHV-8, CMV, and EBV infections
among HIV-AIDS patients and HIV-seronegative healthy
blood donors in Ghana, in an effort to further define the
seroepidemiology and transmission of these infections in
Ghana.
Methods
Study sites and populations
Three thousand two hundred and seventy-five HIV-seron-
egative serum samples were obtained from 7 of the 10
regional blood banks of the Ghana National Blood Trans-
fusion Service from healthy blood donors who gave their
informed consent between 2001 and 2002. In Ghana,
blood donors are volunteers (both occasional and peri-
odic repeat non-compensated volunteer donors) and are
also sought from family members and friends of patients
requiring blood transfusion. They are selected based on
the following criteria: age between 18 and 65 years; weight
>45 kg; haemoglobin >12.5 g/dl; normal blood pressure
[BP], pulse, and body temperature; and not belonging to
any high-risk group (homosexually or heterosexually pro-
miscuous, intravenous drug users; history of sexually
transmitted diseases; and history of any severe current or
chronic illnesses). Donated blood is routinely screened
for HIV 1 & 2, HBsAg, anti-HCV and syphilis antibodies in
Ghana.
Two hundred and fifty HIV-AIDS patients with chronic
diarrhea on admission to the Fevers Unit of the Korle-Bu
Teaching Hospital, Accra, Ghana, were recruited for the
study between February 2001 and June 2002. The Korle-
Bu Teaching Hospital is the leading tertiary hospital in
Ghana that serves the city of Accra, its surrounding urban
population, and the southern part of Ghana. Accra, the
capital city of Ghana, is a rapidly expanding city with a
population of approximately 3 million. All 250 HIV-AIDS
patients (with a single infection from HIV-1) fell within
the Centers for Disease Control and Prevention (CDC)
clinical staging A1–C3 categories, representing asympto-
matic to severe AIDS conditions. The participating HIV-
AIDS patients had mean CD4 counts of 288 cells per
microliter (95% confidence interval of 237–340 cells per
microliter). All participating HIV-AIDS patients reported
watery stools lasting from 3–90 days (diarrhea episodes,
3–10 watery stools per day). The HIV testing for antibod-
ies to HIV-1 and HIV-2 in the study HIV-AIDS patients
and blood donors was done by the particle agglutination
(New Lav Blot I and II; Sanofi Diagnostic Pasteur, Marnes-
la-Coquette, France). The study received ethical review
and approval from the Ethical and Protocol Review Com-
mittee of the University of Ghana Medical School, Accra,
Ghana, and written informed consent was obtained from
all study participants.
Serological analysis
Sera were tested at the Virology Unit, Noguchi Memorial
Institute for Medical Research, for the presence of anti-
bodies to HHV-8 (ELISA; IgG; Advanced Biotechnologies,
Columbia, Maryland, USA), antibodies to CMV (ELISA;
IgG; Diamedix Corporation, Miami, Florida, USA), and
antibodies to EBV (ELISA; IgG antibody to viral capsid
antigen; Advanced Biotechnologies, Columbia, Maryland,
USA), in accordance with the respective manufacturer's
instructions. Positive and negative standard sera, accom-
panying the kit were included in each assay.
Statistical analysis
The Statistical Analysis System (SAS Institute, Cary, NC,
USA) version 9.1 was used to complete all data analyses.
Seropositivity rates were calculated and compared by gen-
der and among different 10-year interval age groups. Dif-
ferences were evaluated using the Chi-square test with
Yates correction. A P value of < 0.05 was considered statis-
tically significant.
Results
Of the 3275 HIV-seronegative healthy blood donors
tested, 2573 (78.6%) were males and 702 (21.4%) were
females, with ages ranging from 18 to 65 years (median
32.6; mean 31.2; mode 30). Of the 250 HIV-AIDS patients
tested, 140 (56%) were males and 110 (44%) were
females, with ages ranging from 17 to 64 years (median
30.8; mean 30.3; mode 28).
Table 1 shows HHV-8, CMV and EBV seropositivity
according to age and gender among the 3275 HIV-seron-
egative healthy blood donors in Ghana. Among the 3275
HIV-seronegative healthy blood donors, overall seroprev-
alence of HHV-8, CMV and EBV was 23.7%, 77.6% and
20.0%, respectively (Table 1). There was no statistically
significant (p > 0.05) difference in the overall seropreva-
lence of HHV-8 between male and female HIV-seronega-
tive healthy blood donors. Additionally, there was no
statistically significant (p > 0.05) difference in the overall
seroprevalence of CMV between male and female HIV-
seronegative healthy blood donors. Finally, there was no
statistically significant (p > 0.05) difference in the overall
seroprevalence of EBV between male and female HIV-
seronegative healthy blood donors [Table 1]. Hence, gen-
der was not an independent determinant (p > 0.05) for allPage 3 of 8
(page number not for citation purposes)
test (Serodia HIV-1 and HIV-2; Serodia Fujirebio Inc.,
Tokyo, Japan) and confirmed by Western blot analysis
three infections among HIV-seronegative healthy blood
donors in Ghana.
BMC Infectious Diseases 2008, 8:111 http://www.biomedcentral.com/1471-2334/8/111
Table 2 shows HHV-8, CMV and EBV seropositivity
according to age and gender among the 250 HIV-AIDS
patients in Ghana. Among the 250 HIV-AIDS patients,
overall seroprevalence of HHV-8, CMV and EBV was
65.6%, 59.2% and 87.2%, respectively (Table 2). There
was no statistically significant (p > 0.05) difference in the
overall seroprevalence of HHV-8 between male and
female HIV-AIDS patients. Additionally, there was no sta-
tistically significant (p > 0.05) difference in the overall
seroprevalence of CMV between male and HIV-AIDS
patients. Finally, there was no statistically significant (p >
0.05) difference in the overall seroprevalence of EBV
between male and HIV-AIDS patients [Table 2]. Hence,
gender was not an independent determinant (p > 0.05)
for all three infections among HIV-AIDS patients in
Ghana.
Table 3 shows the comparison of seroprevalence of HHV-
8, CMV and EBV between HIV-seronegative healthy blood
donors and HIV-AIDS patients in Ghana by age and gen-
der. The overall seroprevalence of HHV-8 was statistically
significantly (p < 0.005) higher in HIV-AIDS patients
(65.6%, 164/250) compared to HIV-seronegative healthy
blood donors (23.7%, 777/3275). Additionally, the sero-
prevalence of HHV-8 was statistically significantly (p <
0.005) higher in male HIV-AIDS patients (62.9%, 88/
140) compared to male HIV-seronegative healthy blood
donors (22.0%, 567/2573). Furthermore, the seropreva-
lence of HHV-8 was statistically significantly (p < 0.05)
higher in female HIV-AIDS patients (69.1%, 76/110)
compared to female HIV seronegative healthy blood
donors (29.9%, 210/702). Finally, the seroprevalence of
HHV-8 was statistically significantly (p < 0.05) higher in
HIV-AIDS patients compared to HIV-seronegative healthy
blood donors within each of the five 10-year interval age
groups (Table 3).
There was no statistically significant (p = 0.24) difference
in the overall seroprevalence of CMV between HIV-AIDS
patients and HIV-seronegative healthy blood donors.
Additionally, the seroprevalence of CMV was not statisti-
cally significantly (p = 0.19) different between male HIV-
AIDS patients and male HIV-seronegative healthy blood
donors. Furthermore, the seroprevalence of CMV was not
Table 1: HHV-8, CMV and EBV seropositivity according to age and gender among the 3275 HIV-seronegative healthy blood donors in 
Ghana
Age group, 
years
Proportion (%) of HIV-seronegative blood 
donors with HHV8 seropositivity
Proportion (%) of HIV-seronegative blood 
donors with CMV seropositivity
Proportion (%) of HIV-seronegative blood 
donors with EBV seropositivity
Male Female All Male Female All Male Female All
16–25 104/681 
(15.3)
65/335 
(19.4)
169/1016 
(16.6)
558/681 
(81.9)
232/335 
(69.3)
790/1016 
(77.8)
108/681 
(15.9)
74/335 
(22.1)
182/1016 
(17.9)
26–35 241/1120 
(21.5)
88/220 
(40.0)
329/1340 
(24.6)
831/1120 
(74.2)
158/220 
(71.8)
989/1340 
(73.8)
35/1120 
(3.1)
28/220 
(12.7)
63/1340 
(4.7)
36–45 118/478 
(24.7)
29/74 (39.2) 147/552 
(26.6)
423/478 
(88.5)
57/74 (77.0) 480/552 
(87.0)
223/478 
(46.7)
36/74 (48.6) 259/552 
(46.9)
46–55 48/158 
(30.4)
12/42 (28.6) 60/200 
(30.0)
101/158 
(63.9)
37/42 (88.1) 138/200 
(69.0)
76/158 
(48.1)
18/42 (42.9) 94/200 
(47.0)
56–65 56/136 
(41.2)
16/31 (51.6) 72/167 
(43.1)
120/136 
(88.2)
25/31 (80.6) 145/167 
(86.8)
40/136 
(29.4)
18/31 (58.1) 58/167 
(34.7)
Total 567/2573 
(22.0)
210/702 
(29.9)
777/3275 
(23.7)
2033/2573 
(79.0)
509/702 
(72.5)
2542/3275 
(77.6)
482/2573 
(18.7)
174/702 
(24.8)
656/3275 
(20.0)
Table 2: HHV-8, CMV and EBV seropositivity according to age and gender among the 250 HIV-AIDS patients in Ghana
Age group, 
years
Proportion (%) of HIV-AIDS patients with 
HHV8 seropositivity
Proportion (%) of HIV-AIDS patients with 
CMV seropositivity
Proportion (%) of HIV-AIDS patients with 
EBV seropositivity
Men Women All Men Women All Men Women All
16–25 11/18 (61.1) 13/19 (68.4) 24/37 (64.9) 12/18 (66.7) 10/19 (52.6) 22/37 (59.5) 16/18 (88.9) 14/19 (73.7) 30/37 (81.1)
26–35 36/49 (73.5) 29/41 (70.7) 65/90 (72.2) 31/49 (63.3) 28/41 (68.3) 59/90 (65.6) 45/49 (91.8) 35/41 (85.4) 80/90 (88.9)
36–45 24/38 (63.2) 21/35 (60.0) 45/73 (61.6) 22/38 (57.9) 19/35 (54.3) 41/73 (56.2) 35/38 (92.1) 30/35 (85.7) 65/73 (89.0)
46–55 12/20 (60.0) 9/16(56.3) 21/36 (58.3) 10/20 (50.0) 8/16 (50.0) 18/36 (50.0) 17/20 (85.0) 14/16 (87.5) 31/36 (86.1)
56–65 5/8 (62.5) 4/6 (66.7) 9/14 (64.3) 5/8 (62.5) 3/6 (50.0) 8/14 (57.1) 7/8 (87.5) 5/6 (83.3) 12/14 (85.7)
Total 88/140 76/110 164/250 80/140 68/110 148/250 122/140 96/110 218/250 Page 4 of 8
(page number not for citation purposes)
(62.9) (69.1) (65.6) (57.1) (61.8) (59.2) (87.1) (87.3) (87.2)
BMC Infectious Diseases 2008, 8:111 http://www.biomedcentral.com/1471-2334/8/111
statistically significantly (p = 0.36) different between
female HIV-AIDS patients and female HIV seronegative
healthy blood donors. Finally, the seroprevalence of CMV
was not statistically significantly (p > 0.05) different
between HIV-AIDS patients and HIV-seronegative healthy
blood donors within each of the five 10-year interval age
groups (Table 3).
The overall seroprevalence of EBV was statistically signifi-
cantly (p < 0.001) higher in HIV-AIDS patients (87.2%,
218/250) compared to HIV-seronegative healthy blood
donors (20.0%, 656/3275) [Table 3]. Additionally, the
seroprevalence of EBV was statistically significantly (p <
0.0005) higher in male HIV-AIDS patients (87.1%, 122/
140) compared to male HIV-seronegative healthy blood
donors (18.7%, 482/2573). Furthermore, the seropreva-
lence of EBV was statistically significantly (p < 0.005)
higher in female HIV-AIDS patients (87.3%, 96/110)
compared to female HIV seronegative healthy blood
donors (24.8%, 174/702). Finally, the seroprevalence of
EBV was statistically significantly (p < 0.05) higher in HIV-
AIDS patients compared to HIV-seronegative healthy
blood donors within each of the five 10-year interval age
groups (Table 3).
The seroprevalence of HHV-8 among HIV-seronegative
healthy blood donors increased with increasing age; with
lowest (16.6%) in 16–25 age group, through 24.6% in
26–35 age group, 26.6% in 36–45 age group, 30.0% in
seropositivity among HIV-seronegative healthy blood
donors with increasing age did not reach the level of sta-
tistical significance (p for trend > 0.05, data not shown).
The seroprevalence of HHV-8 among HIV-AIDS patients
was lowest (58.3%) in 46–55 age group and highest
(72.2%) in 26–35 age group (Tables 2 &3), and there was
no statistically significant difference in HHV-8 seroposi-
tivity among HIV-AIDS patients between the different age
groups (p for trend > 0.05, data not shown). The seroprev-
alence of CMV among HIV-seronegative healthy blood
donors was lowest (69.0%) in 46–55 age group and high-
est (87.0%) in 36–45 age group (Tables 1 &3), and there
was no statistically significant difference in CMV seropos-
itivity among HIV-seronegative healthy blood donors
between the different age groups (p for trend > 0.05, data
not shown). The seroprevalence of CMV among HIV-AIDS
patients was lowest (50.0%) in 46–55 age group and
highest (65.6%) in 26–35 age group (Tables 2 &3), and
there was no statistically significant difference in CMV
seropositivity among HIV-AIDS patients between the dif-
ferent age groups (p for trend > 0.05, data not shown). The
seroprevalence of EBV among HIV-seronegative healthy
blood donors was lowest (4.7%) in 26–35 age group and
highest (47.0%) in 46–55 age group (Tables 1 &3), and
there was no statistically significant difference in EBV
seropositivity among HIV-seronegative healthy blood
donors between the different age groups (p for trend >
0.05, data not shown). The seroprevalence of EBV among
HIV-AIDS patients was lowest (81.1%) in 16–25 age
Table 3: Comparison of seroprevalence of HHV-8, CMV and EBV between HIV-seronegative healthy blood donors and HIV-AIDS 
patients in Ghana by age and gender
Patient 
characteristic
Proportion (%) of HHV-8 seropositives Proportion (%) of CMV seropositives Proportion (%) of EBV seropositives
HIV- HIV+ *P value HIV- HIV+ *P value HIV- HIV+ *P value
Age group, 
years
16–25 169/1016 
(16.6)
24/37 (64.9) < 0.001 790/1016 
(77.8)
22/37 (59.5) 0.26 182/1016 
(17.9)
30/37 (81.1) < 0.0005
26–35 329/1340 
(24.6)
65/90 (72.2) < 0.005 989/1340 
(73.8)
59/90 (65.6) 0.45 63/1340 (4.7) 80/90 (88.9) < 0.0001
36–45 147/552 
(26.6)
45/73 (61.6) < 0.05 480/552 (87.0) 41/73 (56.2) 0.10 259/552 
(46.9)
65/73 (89.0) < 0.05
46–55 60/200 (30.0) 21/36 (58.3) < 0.05 138/200 (69.0) 18/36 (50.0) 0.25 94/200 (47.0) 31/36 (86.1) < 0.05
56–65 72/167 (43.1) 9/14 (64.3) < 0.05 145/167 (86.8) 8/14 (57.1) 0.12 58/167 (34.7) 12/14 (85.7) < 0.05
Gender
Male 567/2573 
(22.0)
88/140 (62.9) < 0.005 2033/2573 
(79.0)
80/140 (57.1) 0.19 482/2573 
(18.7)
122/140 
(87.1)
< 0.0005
Female 210/702 
(29.9)
76/110 (69.1) < 0.05 509/702 (72.5) 68/110 (61.8) 0.36 174/702 
(24.8)
96/110 (87.3) < 0.005
Total 777/3275 
(23.7)
164/250 
(65.6)
< 0.005 2542/3275 
(77.6)
148/250 
(59.2)
0.24 656/3275 
(20.0)
218/250 
(87.2)
< 0.001
*Comparison between HIV-seronegative blood donors and HIV-AIDS patients using the chi-square test with Yates correction.Page 5 of 8
(page number not for citation purposes)
46–55 age group, and highest (43.1%) in 56–65 age
group (Tables 1 &3). However, the increasing HHV-8
group and highest (89.0%) in 36–45 age group (Tables 2
&3), and there was no statistically significant difference in
BMC Infectious Diseases 2008, 8:111 http://www.biomedcentral.com/1471-2334/8/111
EBV seropositivity among HIV-AIDS patients between the
different age groups (p for trend > 0.05, data not shown).
Hence, age was not an independent determinant (p >
0.05) for all three infections among both HIV-seronega-
tive healthy blood donors and HIV-AIDS patients in
Ghana.
Discussion
Several studies have suggested that HHV-8 transmission
may differ between endemic and non-endemic countries.
In countries where infection is highly endemic, HHV-8
seroprevalence is very low in children under 2 years of age
and increases soon after that age [16-19]. These seroepide-
miologic studies suggest that HHV-8 is mainly transmit-
ted among family members and close contacts via a
horizontal, non-sexual route; transmission during preg-
nancy and through breastfeeding having a minimal role in
propagating the virus [16-21]. Other studies have sug-
gested that sexual transmission also occurs in endemic
populations [17,22-24]. Volpi and colleagues [23]
recently demonstrated a statistically significant associa-
tion between HHV-8 and HSV-2 (a prototypic sexually
transmitted infection) in Northern Cameroon (a HHV-8
endemic African country), thus suggesting sexual trans-
mission of these two viruses with HSV-2 probably facili-
tating the sexual transmission of HHV-8 infection in
endemic countries. Additionally, Rezza and colleagues
[24] demonstrated a statistically significant association
between HIV, HHV-8 and EBV in Northern Cameroon,
thus suggesting their shared mode of transmission. In
non-endemic countries, heterosexual transmission is
probably not frequent [25]. In contrast, sexual transmis-
sion is more common among men who have sex with
men in non-endemic countries [18]. Several studies have
demonstrated that saliva is the principal reservoir for
HHV-8, whereas the viral load of HHV-8 is consistently
lower in peripheral blood, secretions from genital sites,
and semen [17,18,26,27]. Therefore, although HHV-8
may be transmitted mainly through saliva in endemic
countries like Ghana and Cameroon, sexual transmission
may be an important additional mode of transmission in
endemic African population [17,22-24].
The herein reported high seroprevalence of HHV-8 in
both HIV-seronegative healthy blood donors (23.7%)
and HIV-AIDS patients (65.6%) confirms that HHV-8 is
endemic in Ghana, and is consistent with the range of
32.3–45.5% previously reported in Ghana [3,13]. Addi-
tionally, our finding confirms the known endemicity of
HHV-8 in the general population of African countries
[4,11]. However, the herein reported HHV-8 seropreva-
lence rate of 23.7% among Ghanaian healthy blood
donors is higher than the recently reported HHV-8 sero-
The herein reported prevalence rate of 77.6% for CMV IgG
among HIV-seronegative healthy blood donors is compa-
rable to the rate (93.2% for CMV IgG) recently reported
among a smaller sample of HIV-seronegative healthy
blood donors at one blood bank in Ghana [14]. The high
CMV seropositivity rate in Ghana is suggestive of ubiqui-
tous past exposure to infection. The high CMV seroposi-
tivity rate in blood donors reported in this study is
comparable to the rates reported in Tunisia (97.0%) [29]
and India (96.0%) [30], respectively. Additionally, the
hyperendemicity of CMV in Ghana may explain the
herein reported lack of statistically significant differences
in the seroprevalence of CMV in HIV-seronegative healthy
blood donors and HIV-AIDS patients between the sexes
and the different age groups.
The herein reported significantly higher seroprevalence of
HHV-8 and EBV in HIV-AIDS patients compared to HIV-
seronegative healthy blood donors suggests that sexual
transmission might play an important role among high-
risk sexual behaviour populations, such as HIV-seroposi-
tive individuals. The herein significantly higher seroprev-
alence of HHV-8 in HIV-AIDS patients compared to HIV-
seronegative healthy blood donors is consistent with one
previous study in Ghana, which reported statistically sig-
nificant (p < 0.05) difference in HHV-8 seroprevalence
rate between HIV-seronegative healthy blood donors
(32.3%) and asymptomatic HIV-seropositive individuals
(45.5%) [13]. However, the herein reported comparably
high seroprevalence of HHV-8, CMV and EBV during both
adolescence and adulthood suggests that their transmis-
sion might occur primarily through horizontal, non-sex-
ual, contact. Indeed, this is particularly evident in African
populations where high prevalence rates have been
observed in infants and children, with seroprevalence
rates similar to that observed in adults [4,11,20,21]. This
large seroepidemiology study supports the view that these
three viral infections are primarily transmitted non-sexu-
ally in Ghana. Therefore, non-sexual transmission mainly
through close interpersonal (especially between mother
and child and among siblings) contact of non-intact skin
or mucous membranes with blood containing secretions
or saliva, may be the primary mode of transmission of
HHV-8 in Ghana, similar to that suggested in previous
reports from endemic areas [4,11,20,21]. However, the
relatively smaller number of HIV-AIDS patients compared
to HIV-seronegative healthy blood donors in this study
may be a limitation. Therefore, we suggest that further epi-
demiological studies should be carried out in Ghana in
order to understand the relationship between HIV and
HHV-8 infection in association with KS among the gen-
eral population and HIV-infected individuals.Page 6 of 8
(page number not for citation purposes)
prevalence rate of 11.5% among blood donors in Burkina
Faso [28], the immediate northern neighbour of Ghana.
An important issue that has major public health implica-
tions is the possibility of transmission of HHV-8, CMV
BMC Infectious Diseases 2008, 8:111 http://www.biomedcentral.com/1471-2334/8/111
and EBV through blood transfusion [7,8,31,32], espe-
cially in hyperendemic countries such as Ghana. Of these
three viruses, cytomegalovirus (CMV) is the only one that
has assumed very significant importance in blood transfu-
sion [32]. The American Association of Blood Banks rec-
ommends the transfusion of "CMV-safe" (CMV-
seronegative or leukocyte-reduced) blood to at-risk indi-
viduals, and this has been the standard of care in most
developed countries since the late 1980s. These guidelines
have helped in drastically minimizing transfusion-trans-
mitted CMV infection in immunosuppressed recipients
[32-34]. The observed high seroprevalence of CMV among
Ghanaian blood donors does not justify pre-donation
blood donor screening for this virus in Ghana because
CMV serology is just a proxy of viremia, blood donor
screening for CMV would be an obstacle to blood supply
in Ghana, and CMV-seronegative blood is recommended
only for organ recipients or other immunosuppressed
patients. However, it does justify post-donation testing of
donated blood in Ghana for CMV in order to identify the
very few CMV-seronegative blood donors, motivate these
CMV-seronegatives to become periodic repeat non-com-
pensated volunteer donors, maintain a database of the
epidemiological and contact information of these CMV-
seronegatives to enable their rapid recall in times of need,
and educate and counsel these CMV-seronegatives on
how to maintain their status and the importance of their
status for themselves and the increasing immunosup-
pressed population in Ghana. Additionally, the above
proposed post-donation testing of donated blood for
CMV and the subsequent determination of the actual
titres of neutralization antibodies in the numerous CMV-
seropositives will ensure the identification of those CMV-
seropositives with very high neutralizing antibody titres
from whom immunoglobulins can be obtained to treat
CMV infections in at-risk individuals, and who will be fol-
lowed-up and recalled when necessary in the same man-
ner described above for the few CMV-seronegatives.
However, the maintenance of CMV-seropositive and
CMV-seronegative "dual inventories" in blood banks is
expensive, and some countries with high CMV seropreva-
lence have found it difficult to maintain adequate sup-
plies of CMV-seronegative products [35], as would be the
case for a developing country such as Ghana. Thus, alter-
nate methods for the provision of "CMV safe" blood prod-
ucts have been pursued, including the use of leukocyte-
reduced blood products. The question whether the use of
CMV-seronegative versus leukocyte-reduced blood com-
ponents is equally efficacious in preventing transfusion-
acquired CMV infection remains unresolved in the litera-
ture [36,37]. Bowden and colleagues reported that the use
of leukocyte-reduced blood products was comparable to
the use of CMV-seronegative blood products for the pre-
of the available controlled studies indicated that CMV-
seronegative blood components were more efficacious
than leukocyte-reduced blood components in preventing
transfusion-acquired CMV infection [37].
Conclusion
The high seroprevalence of the three viruses among both
HIV-positive and HIV-negative individuals suggests ende-
micity and predominant horizontal, non-sexual, trans-
mission of the infections in Ghana. The higher
seroprevalence of HHV-8 and EBV among HIV-AIDS
patients compared to healthy blood donors suggests an
additional role of sexual transmission.
Abbreviations
AIDS: acquired immunodeficiency syndrome; CMV:
cytomegalovirus; EBV: Epstein Barr virus; HHV-8: human
herpes virus 8; HIV: human immunodeficiency virus;
KSHV: Kaposi's sarcoma-associated herpesvirus; OR: odds
ratio; 95% CI: 95% confidence interval
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AAA conceived study, provided guidance to all aspects of
study, and revised manuscript for important intellectual
content. HBA performed quality assessment of data, data
analysis, data preparation, and drafted manuscript. AAA,
HBA, FG, IB, CA and IA participated in design and coordi-
nation of study, data and sample collection, and per-
formed and supervised immunoassays. All authors read
and approved final manuscript.
Acknowledgements
We are grateful to the staff of the Ghana Prison Service, Accra, Ghana, for 
their cooperation and assistance. For technical, logistical and clerical sup-
port, we thank David Adjei, Edward Adjei, Samuel Adjei, Lizabertha Appiah, 
Loretta Antwi, Emelia Ampiah, Ama Afarh, Cecilia Smith, and Emmanuel 
Ametepe, all of who are from the University of Ghana Medical School. This 
work was funded by research grants from the Ghana AIDS Commission, 
Accra, Ghana; the Ministry of Finance, Accra, Ghana; and the Health 
Research Unit, Ghana Health Service, Ministry of Health, Accra, Ghana 
through the Ghana-Dutch Collaborative Programme for Health Research 
and Development.
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