HIV This Week

HIV-infected former plasma donors in rural central China: from infection to survival outcomes, 1985-2008

Dou Z, Chen RY, Wang Z, Ji G, Peng G, Qiao X, Fu J, Meng X, Bulterys M, Ma Y, Zhao Y, Wang N, Zhang F. PLoS One. 2010 Oct 29; 5(10):e13737.

The HIV epidemic among former plasma donors in rural central China in the early-mid 1990s is likely the largest known HIV-infected cohort in the world related to commercial plasma donation but has never been fully described. The objectives of this study are to estimate the timing and geographic spread of HIV infection in this cohort and to demonstrate the impact of antiretroviral therapy on survival outcomes. HIV-infected former plasma donors were identified using the national HIV epidemiology and treatment databases. Locations of subjects were mapped. Dates of infection and survival were estimated using the midpoint date between initial-final plasma donation dates from 1985-2008 among those with plasma donation windows ≤2 years. Among 37084 former plasma donors in the two databases, 36110 were included. 95% were located in focal areas of Henan province and adjacent areas of surrounding provinces. Midpoint year between initial-final plasma donation dates was 1994 among former plasma donors with known donation dates. Median survival from infection to AIDS was 11.8 years and, among those not treated, 1.6 years from AIDS to death. Among those on treatment, 71% were still alive after five years. Using Cox proportional hazard modelling, untreated AIDS patients were 4.9 times (95% confidence interval 4.6-5.2) more likely to die than those on treatment. The epidemic of HIV-infected former plasma donors in China was not widespread throughout China but rather was centred in Henan Province and the adjacent areas of surrounding provinces. Even in these areas, infections were concentrated in focal locations. Overall, HIV infections in this cohort peaked in 1994, with median survival of 13.4 years from infection to death among those not treated. Among AIDS patients on treatment, 71% were still alive after five years.

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Editors’ note: These survival figures are biased upwards because many people had likely died by 2004 when mass HIV screening identified tens of thousands of former plasma donors with HIV infection across central China. Commercial plasma collection had already been stopped for many years (1996). The full story from 1990 to 2004 remains to be told but the Chinese government responded to the 2004 screening results by setting up a free treatment programme for former plasma donors that eventually scaled up to the national level. Why did these primarily poor male farmers come to commercial plasma donation stations in the first place? Plasma donation involved giving blood and receiving pooled blood cells back from blood-type matched donors. The payment they got in return supplemented meagre farming incomes while the blood cell transfusion back, combined with drinking fluids to replace the plasma, meant that the farmer felt strong for work. Why were commercial plasma donation centres set up in rural Henan province and surrounding areas? Risk factors for blood-transmitted infections such as hepatitis B and HIV were low – there was almost no injecting drug use or sex work in these communities. Donations were screened for hepatitis B which can be transmitted perinatally but not for HIV. The Chinese plasma donor HIV epidemic demonstrates graphically what happens if strict blood-borne pathogen precautions are not followed – beyond the donors, many spouses and children also became infected with HIV.