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

Abstract

Background: The HIV epidemic among former plasma donors (FPDs) 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.

Methodology/principal findings: HIV-infected FPDs 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 37,084 FPDs in the two databases, 36,110 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 FPDs 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 modeling, untreated AIDS patients were 4.9 times (95% confidence interval 4.6-5.2) more likely to die than those on treatment.

Conclusions/significance: The epidemic of HIV-infected FPD in China was not widespread throughout China but rather was centered 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.

Figure 1. Selection criteria for HIV-infected former plasma donors (FPD) included in the analysis.

Selection criteria for the 36110 HIV-infected former plasma donors (FPD) included in the overall analysis, the 16038 FPDs included in the estimation of the date of HIV infection, and the 15030 FPDs included in the survival analysis.

Figure 2. Distribution of HIV infection by region among former plasma donors (FPD) included in the analysis.

Figure 2a: Map of the People's Republic of China showing the geographic distribution of all 36110 HIV-infected FPDs included in this analysis by location. Each dot represents 20 people. Figure 2b: Close-up map of Henan Province and the surrounding province showing the geographic distribution of all HIV-infected FPDs included in this analysis from this region. Each dot represents 20 people. Figure 2c: Close-up map of Henan Province and the surrounding province showing the geographic distribution of only the 16038 HIV-infected FPDs included in this analysis from this region with a ≤2 year plasma donation window. Estimated median peak year of HIV infection is indicated by county. Each dot represents 20 people.

Figure 3. Distribution of the estimated time of HIV infection.

Distribution of the estimated time of HIV infection among the subset of former plasma donors (FPD; N = 25960) with known initial and final plasma donation dates, using the midpoint of the donation window as the date of infection and stratified by the duration of the plasma donation window, from those who only donated once (first and last donation dates the same) to those who donated for more than three years. Dates of Western blot (WB) confirmation of HIV infection and initiating highly active antiretroviral therapy (HAART) are also shown.

Figure 4. Survival from HIV infection to AIDS and from AIDS to death.

Kaplan-Meier plots showing survival from HIV infection to AIDS in former plasma donors with plasma donation window ≤2 years (Figure 4a, N = 15030) and from AIDS to death among the same cohort who were diagnosed with AIDS (N = 12242), stratified by whether or not on highly active antiretroviral therapy (HAART; Figure 4b).