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Detection of HIV-1 infections in blood donors during the pre-seroconversion window period in São Paulo, Brazil

Abstract

By decreasing the pre-seroconversion window period, nucleic acid testing (NAT) has improved the safety of blood products and reduced the risk of transfusion-transmitted infections. Between 2011 and 2017, NAT determinations for approximately 898,202 donations were performed at Fundação Pró-Sangue/Hemocentro de São Paulo (FPS-HSP). Three seronegative HIV-viremic donations were detected. The NAT yield rate per million donations was 3.34 for HIV, and the acute HIV-1 infections detected are described, followed by a brief review of the situation in Brazil.

Keywords:
HIV; NAT-HIV; Window period

INTRODUCTION

According to current legislation in Brazil, high-sensitivity antigen/antibody-based assays for HBV, HCV, HIV-1/2, Chagas disease, syphilis, and HTLV-1/2, as well as nucleic acid testing (NAT) for HBV, HCV, and HIV, are mandatory for blood donation screening11. Ministério da Saúde (MS). Portaria de Consolidação nº 5, de 28 de Setembro de 2017. Anexo IV. Brasília: MS; 2017.. At Fundação Pró-Sangue/Hemocentro de São Paulo (FPS-HSP), one of the largest blood banks in Latin America, 120,000 units of blood are collected annually. However, due to a positive reaction for one or more infection markers, approximately 2% of these donations are discarded; of these, the HIV discard rate was 0.11% in 2016. Overall, the introduction of nucleic acid testing (NAT) has improved the safety of blood products and reduced the risk of transfusion-transmitted infections by decreasing the pre-seroconversion window period22. Busch MP, Kleinman SH, Nemo GJ. Current and emerging infectious risks of blood transfusions. JAMA. 2003;289(8):959-62.. Our study aims to determine the HIV NAT-yield and to describe the acute HIV-1 infections detected between 2011 and 2017.

CASE REPORT

Between 2011 and 2017, NAT determinations for approximately 898,202 donations were performed at FPS-HSP, and 3 seronegative HIV-viremic donations were detected. The NAT yield rate per million donations was 3.34 for HIV and the cases are described below.

HIV-1/2 antibody and antigen screening was performed using the chemiluminescent immunoassay (CMIA) kit HIV Ag/Ab Combo Architect System (Abbott, Germany) and/or the enzyme immunoassay (EIA) kit Genscreen Ultra HIV Ag/Ab (Biorad, France). Additionally, NAT assays were performed in minipools (MP) of six samples using the Kit NAT HIV/HCV/HBV (Bio-Manguinhos, Brazil; sensitivity: 95%; LOD: 30 IU/mL or 13-39.9 copies/mL for HIV), and reactive minipools were resolved by individual donation (ID)-NAT screening. CMIA HIV-reactive samples were confirmed by HIV western blotting (MP Diagnostics, Singapore).

In the samples with sufficient serum, a quantitative HIV RNA real-time reverse transcription-polymerase chain reaction (RT-PCR), targeting a portion of the HIV genome LTR region (sensitivity: 100 copies/mL), was performed using 10 µL of extracted RNA (Magna Pure Compact, Roche, Germany), 300 nM of each primer, 100 nM probe33. Candotti D, Temple J, Owusu-Ofori S, Allain JP. Multiplex real-time quantitative RT-PCR assay for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus type 1. J Virol Methods. 2004;118(1):39-47., and 1X TaqMan Fast Virus One Step Master Mix (Thermo Fisher Scientific, USA). The HIV subtypes and mutation analyses were determined by direct sequencing of the HIV reverse transcriptase (RT) and protease regions, as previously described44. Barreto CC, Nishyia A, Araújo LV, Ferreira JE, Busch MP, Sabino EC. Trends in antiretroviral drug resistance and clade distributions among HIV-1--infected blood donors in Sao Paulo, Brazil. J Acquir Immune Defic Syndr. 2006;41(3):338-41., and use of the online Stanford HIV-SEQ program (http://hivdb.stanford.edu).

Donor 1

A sporadic male donor, 36 years old, resident of São Paulo (Carapicuíba), donated whole blood on April 16, 2013, his eleventh donation in FPS-HSP. Sporadic donors are those whom repeat donation after more than 12 months since the previous donation. The last negative donation for all screening tests was on August 1, 2011. He was married and had finished high school. No common risk factor for HIV was identified by the donor questionnaire. The donation was EIA and CMIA-HIV Ag/Ab-negative, but HIV RNA-positive in ID-NAT (ct 32). The unit was discarded, and the donor was recalled to the blood bank. The laboratory result is presented in Table 1. Seventeen days after the index donation, on May 3, 2013, the new sample was HIV Ag/Ab-reactive, HIV RNA-positive in ID-NAT (ct 17), and the HIV western blot was indeterminate. Twenty-eight days after index donation, on May 14, 2013, all markers were positive, including HIV western blot. A further interview was performed as part of the counseling procedure. On this occasion, the patient answered questions about the potential risk factors involved in exposure to HIV. The donor reported that he had been intimate with four partners (women) in the preceding 12 months and had never used condoms. He was referred to the infectious disease department for management.

TABLE 1:
HIV serologic and molecular test results of seronegative HIV-viremic donations.

Donor 2

A 36-year-old, sporadic male donor, living in São Paulo, donated whole blood on June 11, 2016 (sixth donation). The last negative donation for all screening tests was on July 27, 2013. He was single and graduated in pharmacy faculty. No common risk factors for HIV were identified by the donor questionnaire. The donation was HIV NAT-positive and non-reactive for EIA-HIV. ID-NAT confirmed the presence of HIV-1 RNA (ct 32). Seventeen days after the index donation, on June 28, 2016, the donor tested positive for HIV-1 RNA using ID-NAT screening (ct 24). The donation was EIA-HIV Ag/Ab-reactive and the HIV-1 western blot was positive. He reported no risk on the donor return questionnaire. He was referred for treatment.

Donor 3

On March 27, 2017, a 25-year-old, first-time male donor living in São Paulo donated whole blood at FPS-HSP. No common risk factor for HIV was identified through clinical screening. NAT-HIV in pooled samples was positive and CMIA HIV Ag/Ab screening was negative. ID-NAT confirmed the presence of RNA-HIV (ct 28) and viral load was 3,500 copies/mL. On June 2, 2017, 36 days after the index donation, ID-NAT was positive (ct 32) and viral load was 200 copies/mL. HIV Ag/Ab was detected in the serum, and the HIV-1 western blot complement test was positive. Sequence analysis indicated HIV-1 subtype B, and no resistance to reverse transcriptase and protease inhibitors was found. The donor, who was single, reported that he had been intimate with two partners in the last 12 months, had irregularly used condoms, and had received a piercing more than a year previously. He was referred to the infectious disease department for treatment.

DISCUSSION

Between 2011 and 2017, NAT determinations were performed in the FPS-HSP for approximately 898,202 donations. Three seronegative HIV-viremic donations were detected. The NAT yield rate per million donations was 3.34 for HIV, which is slightly lower than the rates observed in Brazil, varying from 4.38 to 4.62 per 1,000,000 donations55. Rocha D, Andrade E, Godoy DT, Fontana-Maurell M, Costa E, Ribeiro M, et al. The Brazilian experience of nucleic acid testing to detect human immunodeficiency virus, hepatitis C virus, and hepatitis B virus infections in blood donors. Transfusion. 2018;58(4):862-70.. In the USA and Europe, these ratios are less than 0.5 and 0.66 per 1,000,000 donations, respectively, and the rates in Africa are highest (close to 36.78 per 1,000,000 donations)66. Roth WK, Busch MP, Schuller A, Ismay S, Cheng A, Seed CR, et al. International survey on NAT testing of blood donations: expanding implementation and yield from 1999 to 2009. Vox Sang. 2012;102(1):82-90..

The main risk for transfusion safety is a donation during the window period, and both prevalence and incidence are important in estimating the risk of transfusion-transmitted infections. In Brazil, although the prevalence of HIV among donors has been declining over the years, it remains high, at 92.2/100,000 donations77. Sabino EC, Goncalez TT, Carneiro-Proietti AB, Sarr M, Ferreira JE, Sampaio DA, et al. Human immunodeficiency virus prevalence, incidence, and residual risk of transmission by transfusions at Retrovirus Epidemiology Donor Study-II blood centers in Brazil. Transfusion. 2012;52(4):870-9., when compared to other countries, such as the USA, which has a rate of 8.3/100,000 donations88. Crowder LA, Steele WR, Notari IV EP, Hopkins CK, Lima JL, Foster GA, et al. Prevalence, incidence, and risk factors of human immunodeficiency virus infection in blood donors in the Southeastern United States. Transfusion. 2017;57(2):404-11.. The incidence of new HIV infections in blood donors has been steady for decades, with rates ranging from 22.6 to 25.9/100,00044. Barreto CC, Nishyia A, Araújo LV, Ferreira JE, Busch MP, Sabino EC. Trends in antiretroviral drug resistance and clade distributions among HIV-1--infected blood donors in Sao Paulo, Brazil. J Acquir Immune Defic Syndr. 2006;41(3):338-41.,77. Sabino EC, Goncalez TT, Carneiro-Proietti AB, Sarr M, Ferreira JE, Sampaio DA, et al. Human immunodeficiency virus prevalence, incidence, and residual risk of transmission by transfusions at Retrovirus Epidemiology Donor Study-II blood centers in Brazil. Transfusion. 2012;52(4):870-9.; nonetheless, it is still almost higher than that in the USA, with a rate of 3.5/100,000 persons/year88. Crowder LA, Steele WR, Notari IV EP, Hopkins CK, Lima JL, Foster GA, et al. Prevalence, incidence, and risk factors of human immunodeficiency virus infection in blood donors in the Southeastern United States. Transfusion. 2017;57(2):404-11.. Thus, the estimated residual risk in Brazil, from 4.2 to 11.3/1,000,000 donations77. Sabino EC, Goncalez TT, Carneiro-Proietti AB, Sarr M, Ferreira JE, Sampaio DA, et al. Human immunodeficiency virus prevalence, incidence, and residual risk of transmission by transfusions at Retrovirus Epidemiology Donor Study-II blood centers in Brazil. Transfusion. 2012;52(4):870-9., is higher than that in the USA, estimated to be at 1/1,100,000 donations88. Crowder LA, Steele WR, Notari IV EP, Hopkins CK, Lima JL, Foster GA, et al. Prevalence, incidence, and risk factors of human immunodeficiency virus infection in blood donors in the Southeastern United States. Transfusion. 2017;57(2):404-11.. Overall, transfusion safety depends greatly on measures or strategies for reducing the incidence of new infections.

Transmission of HIV through transfusion of contaminated blood components was documented despite the implementation of NAT screening. A patient with acute myeloid leukemia received a unit of red blood cells that contained HIV at a concentration too low to be detected in MP-NAT. Perhaps the use of an individual NAT, or more sensitive methodologies, might have prevented this transmission99. Salles NA, Levi JE, Barreto CC, Sampaio LP, Romano CM, Sabino EC, et al. Human immunodeficiency virus transfusion transmission despite nucleic acid testing. Transfusion. 2013;53(10 Pt 2):2593-5.. Indirect strategies, such as methods for raising awareness of the immunological window period among donors, methods for understanding the motives of the donor, and the identification of test takers, may also aid in increasing transfusion safety1010. Goncalez T, Sabino E, Sales N, Chen YH, Chamone D, Busch M, et al. Human immunodeficiency virus test-seeking blood donors in a large blood bank in São Paulo, Brazil. Transfusion. 2010;50(8):1806-14..

In the present study, the donor 3 sample was classified as HIV-1 subtype B, which is the most prevalent subtype in our population. The distribution of HIV subtypes in Brazil is reported to be 75-81% for subtype B, 7-15% for subtype F, 3.8-5% for subtype C, and 4-7.6% for recombinant subtypes among blood donors44. Barreto CC, Nishyia A, Araújo LV, Ferreira JE, Busch MP, Sabino EC. Trends in antiretroviral drug resistance and clade distributions among HIV-1--infected blood donors in Sao Paulo, Brazil. J Acquir Immune Defic Syndr. 2006;41(3):338-41.,1111. Alencar CS, Sabino EC, Carvalho SM, Leao SC, Carneiro-Proietti AB, Capuani L, et al. HIV genotypes and primary drug resistance among HIV-seropositive blood donors in Brazil: role of infected blood donors as sentinel populations for molecular surveillance of HIV. J Acquir Immune Defic Syndr . 2013;63(3):387-92.. In the USA and Europe, the most prevalent, subtype B, ranges from 81 to 95%1212. Delwart E, Slikas E, Stramer SL, Kamel H, Kessler D, Krysztof D, et al. Genetic diversity of recently acquired and prevalent HIV, hepatitis B virus, and hepatitis C virus infections in US blood donors. J Infect Dis. 2012;205(6):875-85.. No antiretroviral drug resistance variants were detected in the studied case. Other studies have verified an increase in primary drug resistance over the years, with a frequency of 6% between 1998 and 2002 and 19% between 2007 and 2011 among blood donors44. Barreto CC, Nishyia A, Araújo LV, Ferreira JE, Busch MP, Sabino EC. Trends in antiretroviral drug resistance and clade distributions among HIV-1--infected blood donors in Sao Paulo, Brazil. J Acquir Immune Defic Syndr. 2006;41(3):338-41.,1111. Alencar CS, Sabino EC, Carvalho SM, Leao SC, Carneiro-Proietti AB, Capuani L, et al. HIV genotypes and primary drug resistance among HIV-seropositive blood donors in Brazil: role of infected blood donors as sentinel populations for molecular surveillance of HIV. J Acquir Immune Defic Syndr . 2013;63(3):387-92.. In the USA and some regions of Europe, resistance rates range from 11 to 14%1212. Delwart E, Slikas E, Stramer SL, Kamel H, Kessler D, Krysztof D, et al. Genetic diversity of recently acquired and prevalent HIV, hepatitis B virus, and hepatitis C virus infections in US blood donors. J Infect Dis. 2012;205(6):875-85..

In conclusion, the NAT yield rate per million donations was 3.34 for HIV, and detection of these cases during the pre-seroconversion window period proves that NAT has improved the testing of transfused blood. Blood donors are considered a sentinel population and studies of prevalence, incidence, and molecular characterization of the circulating strains in this group are important to assist in the measures of prevention and dissemination of infections. Continuous research and surveillance about HIV prevalence among blood donors are needed to maintain and evenly increase blood safety in Brazil.

REFERENCES

  • 1
    Ministério da Saúde (MS). Portaria de Consolidação nº 5, de 28 de Setembro de 2017. Anexo IV. Brasília: MS; 2017.
  • 2
    Busch MP, Kleinman SH, Nemo GJ. Current and emerging infectious risks of blood transfusions. JAMA. 2003;289(8):959-62.
  • 3
    Candotti D, Temple J, Owusu-Ofori S, Allain JP. Multiplex real-time quantitative RT-PCR assay for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus type 1. J Virol Methods. 2004;118(1):39-47.
  • 4
    Barreto CC, Nishyia A, Araújo LV, Ferreira JE, Busch MP, Sabino EC. Trends in antiretroviral drug resistance and clade distributions among HIV-1--infected blood donors in Sao Paulo, Brazil. J Acquir Immune Defic Syndr. 2006;41(3):338-41.
  • 5
    Rocha D, Andrade E, Godoy DT, Fontana-Maurell M, Costa E, Ribeiro M, et al. The Brazilian experience of nucleic acid testing to detect human immunodeficiency virus, hepatitis C virus, and hepatitis B virus infections in blood donors. Transfusion. 2018;58(4):862-70.
  • 6
    Roth WK, Busch MP, Schuller A, Ismay S, Cheng A, Seed CR, et al. International survey on NAT testing of blood donations: expanding implementation and yield from 1999 to 2009. Vox Sang. 2012;102(1):82-90.
  • 7
    Sabino EC, Goncalez TT, Carneiro-Proietti AB, Sarr M, Ferreira JE, Sampaio DA, et al. Human immunodeficiency virus prevalence, incidence, and residual risk of transmission by transfusions at Retrovirus Epidemiology Donor Study-II blood centers in Brazil. Transfusion. 2012;52(4):870-9.
  • 8
    Crowder LA, Steele WR, Notari IV EP, Hopkins CK, Lima JL, Foster GA, et al. Prevalence, incidence, and risk factors of human immunodeficiency virus infection in blood donors in the Southeastern United States. Transfusion. 2017;57(2):404-11.
  • 9
    Salles NA, Levi JE, Barreto CC, Sampaio LP, Romano CM, Sabino EC, et al. Human immunodeficiency virus transfusion transmission despite nucleic acid testing. Transfusion. 2013;53(10 Pt 2):2593-5.
  • 10
    Goncalez T, Sabino E, Sales N, Chen YH, Chamone D, Busch M, et al. Human immunodeficiency virus test-seeking blood donors in a large blood bank in São Paulo, Brazil. Transfusion. 2010;50(8):1806-14.
  • 11
    Alencar CS, Sabino EC, Carvalho SM, Leao SC, Carneiro-Proietti AB, Capuani L, et al. HIV genotypes and primary drug resistance among HIV-seropositive blood donors in Brazil: role of infected blood donors as sentinel populations for molecular surveillance of HIV. J Acquir Immune Defic Syndr . 2013;63(3):387-92.
  • 12
    Delwart E, Slikas E, Stramer SL, Kamel H, Kessler D, Krysztof D, et al. Genetic diversity of recently acquired and prevalent HIV, hepatitis B virus, and hepatitis C virus infections in US blood donors. J Infect Dis. 2012;205(6):875-85.
  • Financial Support: The authors declare their research division's own resources.

Publication Dates

  • Publication in this collection
    16 May 2019
  • Date of issue
    2019

History

  • Received
    21 Nov 2018
  • Accepted
    27 Mar 2019
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