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Rare Case of Transfusion-Transmitted HIV Infection Reported

December 1, 2010

A report published in the October 22 edition of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (MMWR) describes the first known case of HIV transmission from a blood transfusion since 2002.

Enhanced screening, including the use of thorough questionnaires to exclude possible HIV-exposed donors and highly sensitive lab tests to identify infected blood donations, have reduced the risk of blood-borne HIV transmission dramatically. The report stated that based on 2007-2008 data, the risk for acquiring HIV infection through blood transfusion today is estimated conservatively to be one case in 1.5 million procedures. Therefore, this case represents a very rare occurrence.

According to the case report, the source of the infection was a man in his 40s who donated whole blood at a Missouri blood center in November 2008. He was not paid for the donation. A “look-back” investigation established that the man was a repeat blood donor (he also donated in June 2008) who falsely reported no HIV risk factors on the eligibility screening questionnaire. Although the two standard lab screening tests of the June donation were negative, the man was most likely infected with the virus a few days before the donation. This “eclipse period” is the time between infection and the development of discernable HIV RNA or antibodies in the plasma. The November donation, however, tested positive.  

An April 2009 interview revealed that though he was married, the donor had sex, often anonymously, with both men and women outside of his marriage, including just before his June 2008 donation. An orally administered rapid HIV test and subsequent test confirmed his HIV-positive status. Further investigations determined that HIV-infected blood components discovered by the Missouri blood center were linked to the man’s November 2008 donation. 

Of the two recipients of the contaminated blood components, one, a patient in Colorado undergoing kidney transplantation, was later confirmed to be HIV positive. An investigation determined that the patient’s infection came from the donor’s blood products. The other, an Arkansas man, died of heart disease two days after receiving the contaminated blood.

“Even though such transmissions are rare, health-care providers should consider the possibility of transfusion-transmitted HIV in HIV-infected transfusion recipients with no other risk factors,” said the report. “It is the responsibility of persons who donate blood to answer screening questionnaires accurately to ensure the safest blood supply possible.”


Read the full report from the October 22, 2010, study in MMWR.