Human Immunodeficiency Virus Infection in Transfusion Recipients and Their Family Members

CDC has received a report of human immunodeficiency virus (HIV) infection among multiply-transfused leukemia patients in New York City. In addition, there have been several reports that persons with transfusion-associated HIV infection have transmitted the virus to their sexual partners and newborn children. All infected transfusion recipients described in these reports had received blood or blood components before routine screening of donated blood for HIV antibody was begun in the spring of 1985. Multiply-Transfused Leukemia Patients

During the past year, four long-term leukemia survivors at Memorial Sloan-Kettering Cancer Center in New York City developed unexplained fever, weight loss, diarrhea, or lymphadenopathy. They subsequently had positive serological tests for HIV antibody. A retrospective study of other multiply-transfused leukemia patients was conducted to determine how many had been infected with HIV. Informed consent was obtained from all living patients. Positive enzyme immunoassay (EIA) tests were confirmed by Western blot assay. Patients known to have other risk factors for HIV infection were excluded from the study.

Sera were located for 182 deceased and obtained from 22 surviving leukemia patients treated during the years 1978-1986. Sixteen of these transfusion recipients were seropositive for HIV antibody (Table 1). They had received a mean of 27 units of packed red blood cells (range 2-56) and 137 units of platelets (range 10-483). Forty-five percent of these 204 patients had acute myelogenous leukemia; 20% had acute lymphocytic leukemia; 13%, chronic myelogenous leukemia; 4%, chronic lymphocytic leukemia; 6%, myelodysplastic syndromes; and 12%, other or unclassified leukemias. There was no correlation between type of leukemia and the presence of HIV antibody. An additional 23 newly diagnosed, untreated, and untransfused leukemia patients were tested and all were seronegative. Additional Case Reports From Other Areas

Case 1: An elderly man with no known risk for AIDS received multiple units of blood in early 1982, including one from a donor who subsequently tested positive for HIV antibody. The recipient developed Pneumocystis carinii pneumonia (PCP) in 1983 and died in 1984. His wife, who did not have any other risk factors for AIDS, had had vaginal intercourse with him until he became ill in late 1982. In late 1984, her HIV antibody test was positive and she was diagnosed as having a type of lymphoma indicative of AIDS (1).

Case 2: A pregnant woman with no other risk factors for AIDS received four units of blood in 1978, including one from a donor who later tested positive for HIV antibody. A son, born in 1980, had failure to thrive beginning at 13 months of age and died with PCP in 1986. The woman, her son, her husband, and the child born shortly after the transfusion all tested positive for HIV antibody. Reported by DA Scheinberg, MD, PhD, GY Minamoto, MD, K Dietz, MS, JWM Gold, MD, T Gee, MD, D Armstrong, MD, J Gabrilove, MD, B Clarkson, MD, N Chein, MS, L Reich, MD, Memorial Sloan-Kettering Cancer Center, DL Morse, MD, State Epidemiologist, New York State Dept of Health; M Batt, MD, Lutheran General Hospital, Park Ridge, HJ Miller, MD, Dept of Medicine, Evanston Hospital, Evanston, B Stevko, MD, Illinois Dept of Public Health; LA Chambers, MD, American Red Cross Blood Services--Northeast Region, Dedham, L Kunches, GF Grady, MD, State Epidemiologist, Massachusetts Dept of Public Health; Div of Blood and Blood Products, Center for Drugs and Biologics, FDA; AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: At present, prevention of HIV infection and AIDS is dependent upon deferral of blood or plasma donation by persons at increased risk for AIDS, testing of donated blood and plasma for HIV antibody, heat treatment of clotting factor concentrates, avoidance of unprotected sexual contact and needle sharing by persons infected with HIV, and prevention of perinatal transmission by infected women. Counseling and HIV antibody testing have been recommended for persons at risk for infection (including homosexual/bisexual men, intravenous drug abusers, hemophilia patients, prostitutes, and persons who have had sexual contact with members of these groups) (2). Routine counseling and antibody testing have not been recommended for blood transfusion recipients because, in general, their risk for infection is extremely low. However, as illustrated by this report and others (3), some multiply-transfused persons may be at a higher risk for HIV infection. In addition, some persons with transfusion-associated HIV infection have transmitted the virus to their sexual partners and, perinatally, to their infant children.

Although the number of infected transfusion recipients in the United States is unknown, it can be approximated using estimates of the prevalence of infection in donors, the efficiency of transmission, and the number of units transfused per year. In 1985, 0.04% of donations were positive for HIV antibody by Western blot assay (4). If 0.04% had been the seroprevalence among donors in the year prior to screening, if all seropositive units had transmitted infection (5), and if each seropositive unit had gone to a different recipient, then 7,200 of the approximately 18 million components transfused in 1984 (American Blood Commission, unpublished data) might have transmitted infection. If 60% of these recipients have died from their underlying disease (6), then approximately 2,900 living recipients who acquired a transfusion-associated HIV infection in 1984 would remain. Most of these would be asymptomatic. The number of infected donors was probably lower in earlier years. Mathematical projections from reported transfusion-associated AIDS cases estimate that approximately 12,000 people now living in the United States acquired a transfusion-associated HIV infection between 1978 and 1984 (7).

Blood banking organizations in the United States have begun "look-back" programs to identify previous recipients of blood from donors who tested positive for HIV antibody after screening began. In one region, 70% of recipients identified through such a program had HIV antibody (8). However, look-back programs cannot identify all infected transfusion recipients because many infected donors may have refrained from donating or become too ill to continue to donate after HIV serologic testing of donors began.

The risk of HIV transmission by transfusion was low, even before screening, and has been virtually eliminated by the routine screening of donated blood and plasma. However, since HIV-infected persons are at risk for developing AIDS or related conditions themselves and may transmit infection to others, physicians should consider offering HIV antibody testing to some patients who received transfusions between 1978 and late spring of 1985. This consideration should be based on the likelihood of infection in a recipient and the likelihood of transmission from that recipient. The risk of infection is greatest if the recipient received large numbers of transfusions and if the blood was collected during the few years before screening in an area with a high incidence of AIDS. (The leukemia patients in this report received many units of blood and blood components in an area with a higher prevalence of HIV than most parts of the United States, so their seropositivity rate is higher than would be expected in other patients. Conversely, persons who received a small number of units in a low prevalence area would have an extremely low risk of HIV infection.) Testing is particularly important if the patient is sexually active. Since the overall prevalence of infection in transfusion recipients is expected to be low, the positive predictive value of EIA screening tests for HIV antibody will be much lower than that seen when testing high-risk populations (9). Therefore, all transfusion recipients with a positive EIA should also have their serum tested by a second method (Western blot assay, immunofluorescence assay) before they are informed of their test result. Seropositive persons should be evaluated for signs and symptoms of AIDS or related conditions and counseled regarding the avoidance of HIV transmission to others.

References

1. Duncan ED, Miller HJ, McKeever WP. Non-Hodgkin's lymphoma, HTLV-III/LAV, and HTLV-III/LAV antibody in the wife of a man with transfusion-acquired AIDS. Am J Med 1986;81:898-900.

2. CDC. Additional recommendations to reduce sexual and drug abuse-related transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus. MMWR 1986;35:152-5.

3. Troy K, Cuttner J, Zaroulis C. Incidence of anti-HIV antibodies in patients with acute leukemia treated between 1978 and 1986 (Abstract). Blood 1986;68:135a.

4. Schorr JB, Berkowitz A, Cumming PD, Katz AJ, Sandler SG. Prevalence of HTLV-III antibody in American blood donors (Letter). N Engl J Med 1985;313:384-5.

5. Ward JW, Deppe DA, Samson S, et al. Risk of human immunodeficiency virus infection from blood donors who later developed the acquired immunodeficiency syndrome. Ann Intern Med 1987;106:61-2.

6. Perkins HA, Samson S, Rosenschein S, et al. Risk of AIDS from

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