Introduction

Blood transfusion is a life-saving medical intervention that has been in use for decades. However, the transmission of transfusion-transmissible infections (TTIs) through blood transfusion remains a significant public health concern [1]. Among transfusion-transmissible infections, HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis are of particular public health importance because they are routinely screened in donated blood under WHO blood safety recommendations and continue to contribute substantially to transfusion-related morbidity and mortality worldwide [2–4].

Globally, there are approximately 170 million individuals chronically infected with hepatitis C virus (HCV), more than 350 million with hepatitis B virus (HBV), and 38 million human immunodeficiency virus (HIV)-infected people [3].

Across sub-Saharan Africa, the burden of transfusion-transmissible infections among blood donors remains substantial, although prevalence varies considerably between countries and settings. Recent studies have reported TTI prevalence ranging from less than 5% in some settings to over 10% in others, reflecting differences in donor selection practices, screening strategies, and underlying population disease burden [5–7].

In Ghana, transfusion-transmissible infections among blood donors remain a significant public health concern despite ongoing improvements in blood safety systems. Previous studies have reported varying prevalence estimates across different parts of the country. A national multicentre study reported an overall TTI prevalence of 21.0%, with HBV (6.6%), HCV (4.9%), HIV (2.9%), and syphilis (6.8%) constituting the major infections among blood donors [8]. Similarly, a study conducted in the Ashaiman Municipality reported prevalence rates of 4.9% for HBV, 1.5% for HCV, and 4.0% for syphilis [1], while a study in the Akatsi South Municipality of the Volta Region reported an overall TTI prevalence of 8.0%, comprising HIV (3.8%), HBV (3.2%), and HCV (1.0%) [9]. These findings highlight substantial geographical variation in TTI prevalence and underscore the importance of continuous surveillance to guide blood safety interventions. The World Health Organization (WHO) recommends screening all donated blood for TTIs to ensure the safety of the blood supply [4]. Despite these recommendations, the prevalence of TTIs among blood donors in Ghana remains high, with studies reporting varying prevalence rates depending on the region and population studied [1]. This highlights the need for ongoing surveillance, particularly in areas like Hohoe and Ho, to better understand and mitigate the risks associated with TTIs in blood donation. This study therefore aimed to determine the seroprevalence and temporal trends of transfusion-transmissible infections (TTIs) among blood donors in Hohoe and Ho, Volta Region, Ghana, and to identify demographic factors associated with seropositivity.

Methods

Study site description

The study was conducted at the Ho Teaching Hospital Blood Bank and the Hohoe Regional Hospital Blood Bank, both located in the Volta Region of Ghana. Ho Teaching Hospital is a tertiary referral facility and a major training center for the University of Health and Allied Sciences, serving the southern Volta Region and neighboring areas. Hohoe Regional Hospital is a key referral facility for the northern Volta and Oti Regions. Together, these facilities provide blood transfusion services to a large and diverse catchment population within the region, which had a total population of approximately 1.66 million people according to the 2021 Population and Housing Census conducted by the Ghana Statistical Service. Both facilities provide blood transfusion services to large and diverse populations and maintain functional blood banks that routinely collect blood from voluntary and family replacement donors.

All donated blood units are screened for transfusion-transmissible infections (TTIs), including HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis, in accordance with national blood safety guidelines. The study site is depicted as Fig 1.

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Fig 1. Showing study and non-study site.

(Administrative boundary data used in map preparation were obtained from the Ghana Statistical Service and processed using ArcMap).

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Results

Demographic characteristics

A total of 6,147 blood donors were included in the analysis, comprising 2,015 (32.8%) from Ho and 4,132 (67.2%) from Hohoe. The overall mean age of donors was 26.9 ± 7.4 years, with donors in Ho being slightly older (28.2 ± 7.9 years) than those in Hohoe (26.3 ± 7.1 years). Majority of donors were aged 20–29 years (55.6%), followed by 30–39 years (23.5%). Donors aged ≥50 years constitute less than 1% of the study population. The donor population was predominantly male (95.1%), with females acc ounting for only 4.9% (Tables 1 and 2).

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Table 1. Demographic characteristics of the blood donors.

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Table 2. Prevalence of transfusion-transmissible infections among blood donors in the blood banks.

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Overall prevalence of transfusion-transmissible infections

The overall prevalence of transfusion-transmissible infections (TTIs) among blood donors was low. The prevalence of HIV was 1.0% (63/6,147), HBV 1.8% (113/6,147), HCV 1.8% (109/6,147), and syphilis 3.6% (219/6,147). Among the TTIs, syphilis was the most prevalent infection, followed by HBV and HCV, which showed similar prevalence levels.

Trends of transfusion-transmissible infections (2020–2023).

Fig 2 shows a clear temporal variation in TTI prevalence over the study period. Across all infections, prevalence was relatively low in 2020 and 2021, followed by a marked increase in 2022, and a subsequent decline in 2023.

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Fig 2. Trends of transfusion-transmissible infections.

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Specifically, HIV prevalence increased from 0.3% in 2021 to 1.6% in 2022, while HBV rose from 0.9% to 3.5%, HCV from 0.7% to 3.8%, and syphilis from 2.3% to 6.6% during the same period. Although prevalence declined in 2023, it remained higher than levels observed in 2020–2021 for most infections.

Site-specific prevalence of TTIs

Ho Blood Bank.

Among donors in Ho (n = 2,015), the prevalence of HIV, HBV, HCV, and syphilis was 1.3%, 3.7%, 1.8%, and 3.1%, respectively. HBV was the most prevalent infection in this site. A notable increase in HBV (8.5%) and syphilis (6.4%) was observed in 2022, followed by a decline in 2023 (Table 3).

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Table 3. Prevalence of transfusion-transmissible infections (TTIs) among blood donors at Ho blood banks.

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Hohoe Blood Bank.

Among donors in Hohoe (n = 4,132), the prevalence of HIV, HBV, HCV, and syphilis was 0.9%, 0.9%, 1.7%, and 3.8%, respectively. Syphilis was the most prevalent infection in this site. Similar, to Ho, all infections peaked in 2022, particularly HCV (3.8%) and syphilis (6.7%), with a reduction observed in 2023 (Table 4).

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Table 4. Prevalence of transfusion-transmissible infections (TTIs) among blood donors at Hohoe blood banks.

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Factors associated with TTIs: Bivariate analysis

Ho Blood Bank.

In Ho, age and year of donation were significantly associated with several TTIs. Increasing age was associated with higher prevalence of HIV (p = 0.02), HBV (p = 0.01), and HCV (p = 0.03). Year of donation was significantly associated with HBV (p < 0.01) and syphilis (p < 0.01), with higher prevalence observed in 2022.

No statistically significant association was observed between gender and any of the TTIs.

Hohoe Blood Bank.

In Hohoe, age and year of donation were also significantly associated with TTIs. Age was significantly associated with HBV (p < 0.01), HCV (p = 0.02), and syphilis (p < 0.01), with higher prevalence observed among older donors.

Gender was significantly associated with HCV infection (p < 0.01), with higher prevalence observed among females compared to males. Year of donation were significantly associated with all TTIs (p < 0.01), with peak prevalence consistently observed in 2022 (Tables 5–7).

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Table 5. Association between demographic characteristics and transfusion-transmissible infections among blood donors in Ho.

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Table 6. Association between demographic characteristics and transfusion-transmissible infections among blood donors in Hohoe.

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Table 7. Multivariable logistic regression analysis of factors associated with transfusion-transmissible infections among Ho and Hohoe blood donors.

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Ho Blood Bank.

After adjusting for potential confounders, age and year of donation remained significant predictors of TTI positivity.

Donors aged ≥50 years had significantly higher odds of HIV infection (aOR = 8.67; 95% CI: 1.37–54.56) and HCV infection (aOR = 21.66; 95% CI: 2.03–230.75) compared to donors aged <20 years.

Donors aged 40–49 years also had increased odds of HBV infection (aOR = 4.36; 95% CI: 1.21–15.61). The year of donation was significantly associated with the incidence of the infections. Compared to 2020, donors in 2022 had higher odds of HBV (aOR = 2.90; 95% CI: 1.58–5.34), HCV (aOR = 2.35; 95% CI: 1.03–5.35), and syphilis (aOR = 3.99; 95% CI: 1.85–8.60).

Gender was not significantly associated with any TTI after adjustment.

Hohoe Blood Bank.

In Hohoe, age, gender, and year of donation were significant predictors of TTIs.

Donors aged ≥50 years had significantly higher odds of HBV (aOR = 82.16; 95% CI: 7.41–910.79), HCV (aOR = 13.14; 95% CI: 2.38–72.42), and syphilis (aOR = 9.40; 95% CI: 2.58–34.15) compared to donors aged <20 years.

Male donors had significantly lower odds of HCV infection compared to females (aOR = 0.13; 95% CI: 0.06–0.28).

Year of donation were strongly associated with all TTIs. Compared to 2020, donors in 2022 had significantly higher odds of HIV (aOR = 5.43; 95% CI: 1.83–16.09), HBV (aOR = 4.06; 95% CI: 1.26–11.48), HCV (aOR = 11.84; 95% CI: 4.56–30.75), and syphilis (aOR = 3.46; 95% CI: 2.12–5.63). Elevated odds persisted in 2023 for all infections

Discussion

This study assessed the seroprevalence and temporal trends of transfusion-transmissible infections (TTIs) among 6,147 blood donors in Ho and Hohoe over a four-year period. The overall TTI prevalence was low with syphilis (3.6%) as the most common infection, followed by HBV (1.8%), HCV (1.8%), and HIV (1.0%). This pattern suggest improved blood safety compared with earlier Ghanaian reports but indicates persistent residual transfusion risk, particularly for vulnerable recipients [2,10].

The observed prevalence is substantially lower than earlier multicenter Ghanaian estimates reporting overall TTI burdens up to 21% and Hohoe-specific historical prevalence exceeding 16% [2,8]. Similar declining trends have been reported in other Ghanaian settings, including Akatsi South (≈8%), suggesting improved donor screening and selection practices across the Volta Region [9]. The reduction likely reflects strengthened pre-donation screening, improved laboratory diagnostics, and stricter donor eligibility criteria implemented over recent years [11,12].

Regionally, findings align with variable, but generally higher TTI burdens have been reported across sub-Saharan Africa. In Nigeria, pooled prevalence estimates are approximately 10%, with HBV typically dominant [10]. In Gabon, HBV (6%), HCV (4%), HIV (3%), and syphilis (3%) remain higher than in the present study [6]. Similarly, Uganda reports an overall prevalence of about 8.7%, with syphilis frequently the leading infection [13]. Southern African pooled estimates remain lower (~2%) but exhibit marked heterogeneity across settings [7].

Globally, high-income countries report TTI prevalence below 1%, largely due to universal voluntary donation systems and advanced screening technologies such as nucleic acid testing (NAT), which significantly reduce window-period infections [14,15]. In contrast, many low- and middle-income countries continue to rely on rapid diagnostic tests, which are less sensitive, potentially underestimating viral infections or missing early-stage disease [16].

The predominance of syphilis in this study contrasts with findings from many West African settings where HBV is often reported as the leading transfusion-transmissible infection but aligns with reports from parts of Ghana, Uganda, and Ethiopia where syphilis remains an important contributor to the burden of TTIs among blood donors [13,17]. The relatively higher prevalence of syphilis may reflect differences in access to sexual and reproductive health services, variations in community-level STI screening and treatment programmes, and delayed healthcare-seeking behaviour among infected individuals.

Furthermore, syphilis infection is frequently asymptomatic during certain stages, allowing infected individuals to remain undiagnosed and untreated for prolonged periods. Regional differences in the implementation of STI prevention initiatives, public awareness programmes, and partner notification services may also contribute to variations in syphilis prevalence between settings [18,19]. While our study did not collect behavioural or cultural data to directly evaluate these factors, they represent plausible explanations that warrant further investigation in future studies. Additionally, differences in test sensitivity may contribute to relative pattern shifts. Treponemal rapid tests, while widely used, may yield variability in detection compared with ELISA-based or confirmatory assays, potentially influencing observed prevalence distributions [16]. The persistence of syphilis as the leading infection underscores the need for strengthened community-level prevention strategies and improved diagnostic algorithms.

A notable finding is the peak in all TTIs in 2022, followed by a decline in 2023. This pattern is consistent with broader African and global reports documenting post-COVID-19 disruptions in blood safety systems [20,21]. The increase in TTI prevalence observed in 2022 should also be interpreted with caution. Different rapid diagnostic test brands were used across the study period based on availability within the participating facilities. Although all reactive screening results were confirmed using Fortress Diagnostics ELISA assays, variations in the diagnostic performance characteristics of screening kits may have contributed to some fluctuations in observed prevalence. Nevertheless, the standardized ELISA confirmation process likely minimized substantial differences in final infection classification across years.

During the pandemic, reduced voluntary donations, increased reliance on replacement donors, and strained laboratory capacity likely contributed to temporary increases in TTI prevalence [22,23].

Similar fluctuations have been reported in Ethiopia, Somalia, Cameroon, and Brazil, where health system shocks altered donor recruitment dynamics and screening efficiency [24–26]. The subsequent decline in 2023 likely reflects restoration of routine services, improved donor recruitment strategies, and reactivation of public health interventions [8,12]. These findings highlight the vulnerability of blood safety systems to external shocks and the importance of resilient haemovigilance frameworks.

Age was a consistent predictor of TTI positivity, with older donors showing higher risk, particularly for HBV and HCV. This is consistent with evidence from multiple African and Asian studies, where cumulative exposure increases infection probability over time [17,26,27]. However, some studies also report higher HBV/HCV prevalence in younger donors in high-risk recruitment systems, highlighting context-specific variation [8,15].

Gender differences were more limited but showed a significant association between male sex and HCV positivity in Hohoe. This aligns with studies from Ethiopia and Angola, where males often exhibit higher HBV/HCV prevalence due to greater representation among donors and higher exposure risk behaviors [17,27]. Conversely, some settings report higher female seroprevalence due to antenatal screening detection bias, illustrating heterogeneous gender patterns across regions [10,28]. Donation year was also a significant predictor, reflecting broader system-level influences such as pandemic disruptions, policy changes, and evolving screening technologies [8,20]. Such temporal variability highlights the importance of continuous surveillance in interpreting TTI trends.

A key structural determinant of TTI risk is reliance on replacement or family donors, who consistently demonstrate higher infection rates than voluntary non-remunerated donors [12,28]. This remains a major challenge in many African blood systems and likely contributes to persistent infections despite overall declining trends. Socio-demographic factors such as younger age distribution, male dominance, and lower repeat donation rates further exacerbate residual risk [8,9].

Conclusion

This study determined a TTI seroprevalence of 8.1% among 6,147 blood donors at two blood banks in Ghana’s Volta Region (2020–2023), which is substantially lower than the national multicentered benchmark of 21.0% and prior Hohoe rates exceeding 16.1% [8,12]. Seroprevalence peaked in 2022 across all pathogens before declining in 2023. Older age was consistently associated with seropositivity, and site-specific burdens of syphilis (3.6%) and HBV/HCV (1.8% each) were identified. The predominance of young male donors and the contribution of replacement donors emerged as key vulnerabilities, particularly during pandemic-related disruptions.

These findings affirm that sustained implementation of national transfusion safety protocols has strengthened the blood supply. However, persistent reservoirs of TTIs necessitate targeted actions: expanding voluntary non-remunerated donor recruitment, integrating point-of-care syphilis testing, adding anti-HBc screening to detect occult HBV infections, and enhancing female and older-donor recruitment. Future prospective multicenter studies incorporating molecular assays and behavioral risk stratification will be essential to further reduce residual risks and ensure Ghana’s blood system meets universal safety standards.

Supporting information

Acknowledgments

The authors gratefully acknowledge the managements and staff of Hohoe and Ho hospitals and their blood banks for permission to conduct the study and use the data. We also thank the blood bank personnel, laboratory staff, and all individuals who provided technical or administrative support. Special appreciation goes to the blood donors whose records formed the basis of this work.