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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 129-134

Seroprevalence and trend of human immunodeficiency virus infection among Indian blood donors: A systematic review and meta-analysis


1 Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
2 Department of Immunohematology and Blood Transfusion, Bharati Vidhyapeeth Medical College and Hospital, Pune, Maharashtra, India
3 Department of Virology, Institute of Liver and Biliary Sciences, New Delhi, India
4 Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
5 The INCLEN Trust International, New Delhi, India

Date of Submission20-May-2020
Date of Decision14-Aug-2020
Date of Acceptance14-Aug-2020
Date of Web Publication13-Nov-2020

Correspondence Address:
Meenu Bajpai
Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_44_20

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  Abstract 


Transfusion-transmitted infections remain a grave concern for blood transfusion services. Thus, our aim was to determine the seroprevalence of human immunodeficiency virus (HIV) infection among Indian blood donors (BDs) and its trend over the past few decades. We searched PubMed and Indmed for studies containing data on HIV seroprevalence among Indian BDs published from January 1989 to December 2017. Pooled HIV seroprevalence, subgroup analysis, and trend of HIV seroprevalence depending upon the year of publication were calculated. Twenty articles met the inclusion criteria. Overall pooled HIV seroprevalence among Indian BDs was 3.22 per 1000 BD (95% confidence interval [CI] 2.65–3.8). Overall pooled HIV seroprevalence was found to be higher among the replacement BD (3.24 per 1000; 95% CI 2.45–4.03) as compared to voluntary BD (1.67 per 1000; 95% CI = 1.09–2.25). Region-wise highest overall pooled HIV seroprevalence was noted among BD from West 4.33 per 1000 (95% CI 0.96–7.7) followed by South 3.49 per 1000 (95% CI 1.47–5.51), East 3.4 per 1000 (95% CI 1.71–5.08), and North 2.76 per 1000 (95% CI 2.05–3.48). A significant rise in overall pooled HIV seroprevalence was noted over the two decades (1995–2005-2.8 per 1000; 2006–2015-3.46 per 1000; I2 = 97.7%; P < 0.001). Overall pooled HIV seroprevalence rate among Indian BDs in our study was 0.32%. There is a need to perform studies that will help in recommending appropriate deferral, selection, and testing strategies in these donors.

Keywords: Blood donor, human immunodeficiency virus, India, seroprevalence, trend


How to cite this article:
Bajpai M, Kakkar B, Gupta E, Kumar G, Mohapatra A. Seroprevalence and trend of human immunodeficiency virus infection among Indian blood donors: A systematic review and meta-analysis. Glob J Transfus Med 2020;5:129-34

How to cite this URL:
Bajpai M, Kakkar B, Gupta E, Kumar G, Mohapatra A. Seroprevalence and trend of human immunodeficiency virus infection among Indian blood donors: A systematic review and meta-analysis. Glob J Transfus Med [serial online] 2020 [cited 2020 Nov 24];5:129-34. Available from: https://www.gjtmonline.com/text.asp?2020/5/2/129/300625




  Introduction Top


Blood transfusion is generally considered safe, but there may be associated risks, of which transfusion transmissible infections (TTIs) remains a grave concern for transfusion medicine specialists throughout the world. Thus, blood safety remains a challenging task for blood transfusion services (BTS) as well as the policy-makers.[1]

The WHO recommends an integrated strategy for improving blood supply safety, which includes well-organized BTS, collection of blood from voluntary nonremunerated donors, testing of the donated blood for TTIs with quality-assured assays, and advocating rational use of blood/blood components among clinicians.[1] Despite having these strategies in place, the residual risk of TTIs still remains due to inability of the tests to detect early seroconverting donors, immunologically variant viruses, immune silent carriers, and technical errors.[2],[3]

According to the United Nations Joint Program on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS, UNAIDS), the estimated global HIV prevalence in the adult population was 0.8% (0.7%–0.9%), whereas it was 0.3% (0.2%–0.3%) for the Indian adult population, at the end of year 2016.[4] A total of 2760 blood banks are in India, of which 1126 are currently under the support of National AIDS Control Organization (NACO). The overall seroprevalence of HIV among Indian blood donors (BDs) in the year 2015 in NACO supported blood banks was found to be 0.136%, with wide variation noted among the seroprevalence rates between the states.[5] BDs are known to represent the healthy general population and the risk TTI's is also very low. Thus, the aim of this study was to perform a systematic review and meta-analysis to determine the seroprevalence of HIV infection among Indian BDs and its trend over time based on the available published literature.


  Materials and Methods Top


A systematic review of the available published literature was conducted according to preferred reporting items for systematic review and meta-analysis guidelines.[6]

Literature search strategy

A comprehensive search was conducted in PubMed and Indmed to identify the relevant studies. To extract the maximum number of articles, the following search strategy was used: HIV OR human AND immunodeficiency OR immunodeficiency AND virus AND blood AND donors OR donation OR bank AND India AND prevalence OR seroprevalence OR burden OR epidemiology OR trend. Articles were searched from November 1, 2017, to January 6, 2018, and relevant articles were included for analysis.

Article selection criteria and data extraction

The selection of relevant articles was performed independently by two reviewers with the resolution of disagreements through discussion and opinion of third reviewer. The assessment of articles for eligibility was done based on the title, abstract and full text, if required.

Articles that met the following criteria were included: (i) Described the seroprevalence of HIV infection among Indian BDs, (ii) conducted among voluntary and replacement BDs, (iii) described the methodology used for HIV detection (third- or fourth-generation enzyme-linked immunosorbent assay, ELISA, and/or Western blot), (iv) published from January 1989 to December 2017 in English, (v) conducted in India, and (vi) either cross-sectional, prospective, or retrospective study. The exclusion criteria were as follows: (i) included commercial/paid donors, (ii) conducted outside India, (iii) review articles, editorials, case reports, or conference abstracts, and (iv) if the study data were duplicated.

The following information was extracted from the eligible articles: Publication year, study center and location, study design, sample size, study period, seroprevalence of HIV infection, methodology used, age, and gender of the study participants.

Data analysis

The data were analyzed to determine the pooled seroprevalence of HIV infection among Indian BDs and for subgroups (type of BD: Voluntary/replacement; studies were divided into two groups depending upon the year of publication to determine the trend, 1995–2005 and 2006–2015; region wise – North, South, West, and East India) with 95% confidence intervals (CIs) using computer software, STATA 12 (StataCorp. 2011. Stata Statistical Software: Release 12. College Station, TX, USA: StataCorp LP). To assess the heterogeneity for each pooled estimate, Cochran's (Q) test (P < 0.05 represented significant heterogeneity) and I2 statistic tests (value >75% represented high heterogeneity and was considered significant) were performed. Random effect models were used to calculate the pooled seroprevalence of HIV for P < 0.05 for Q test. To detect the potential publication bias, Funnel plot and Begg rank correlation test (P < 0.05 was considered significant) were used.


  Results Top


A total of 185 relevant citations were identified through the literature search. Based on title and abstract screening, 151 were excluded. Thirty-four articles were retrieved for further detailed analysis. Of them, 20[2],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] met the inclusion criteria, whereas 14 were excluded due to full-text missing (3), only abstracts available (10), and letter to editor (1). [Figure 1] shows the selection process undertaken,[6] and [Table 1] shows the descriptive summary of the studies included in the analysis.
Figure 1: Flow chart of the systematic literature search performed

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Table 1: Descriptive summary of the studies included in meta-analysis

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Among the 20 studies included for the final analysis, a total of 1,469,817 BDs were evaluated to describe the HIV seroprevalence. The overall pooled HIV seroprevalence rate among Indian BDs was 3.22 per 1000 BDs (95% CI 2.65–3.8). Random effects model was used due to substantial heterogeneity noted between studies [I2 = 97.7%; Q test P < 0.001; [Figure 2]. A significant rise in HIV seroprevalence rate among BDs was noted over the two decades (1995–2005-2.8 per 1000, 95% CI 1.83–3.77; 2006–2015-3.46 per 1000, 95% CI 2.71–4.21; I2 = 97.7%; P < 0.001).
Figure 2: Forest plot of overall pooled human immunodeficiency virus seroprevalence among Indian blood donors

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Of the 20 studies included for the analysis, 13 reported HIV seroprevalence rate among voluntary and replacement BDs. Seroprevalence of HIV was found to be higher among the replacement BDs (3.24 per 1000; 95% CI 2.45–4.03) as compared to voluntary BDs (1.67 per 1000; 95% CI = 1.09–2.25). Ten studies were conducted in Northern India, four in Eastern India, three each in Western and Southern India. Region wise high seroprevalence of HIV was noted in West 4.33 per 1000 BDs (95% CI 0.96–7.7) followed by South 3.49 per 1000 BDs (95% CI 1.47–5.51), East 3.4 per 1000 BDs (95% CI 1.71–5.08), and North 2.76 per 1000 BDs (95% CI 2.05–3.48).

ELISA was predominantly used screening methodology. Of the 20 studies, eleven did not mention the generation of the assay used, five used third-generation assay, two used fourth-generation assay, and one used both third- and fourth-generation assay and one used chemiluminescence immunoassay (CLIA). Only six studies reported the age distribution, whereas seven reported the gender distribution [Table 1]. A funnel plot of the reported HIV seroprevalence rate across the published studies revealed asymmetrical distribution [Figure 3]. Begg rank correlation test revealed no statistical significance (P = 0.456). Some of the articles included did not contain all the variables.
Figure 3: Funnel plot of reported human immunodeficiency virus seroprevalence rate across studies published in India

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  Discussion Top


This study highlights the current status of the seroprevalence and trend of HIV infection among Indian BDs. We observed that (i) the rate of HIV seroprevalence was 3.22 per 1000 BDs (or 0.32%), (ii) high prevalence was noted among the replacement BDs (3.24 per 1000 BDs or 0.32%) in comparison to voluntary BDs (1.67 per 1000 BDs or 0.167%), (iii) a significant rise was also noted in HIV seroprevalence from the one decade (1995–2005-2.8 per 1000 BDs or 0.28%) to another decade (2006–2015-3.46 per 1000 BDs or 0.34%), and (iv) huge variations were also noted among prevalence for different regions.

Due to the active efforts of NACO, a significant decline in the seroprevalence of TTI's among the NACO supported blood banks has been noted over the years.[5] In this study, the overall pooled seroprevalence of HIV was found to be 0.32%, which was found to be significantly higher than the HIV seroprevalence rate reported by the NACO (0.136%; 2015),[5] while it was to the similar HIV seroprevalence rate reported in the adult Indian population (0.3%; 2016).[4] The estimated HIV seroprevalence rate (2016) in India among different key population such as sex workers, men who has sex with men, intravenous drug abusers, and transgender people were 2.2%, 4.3%, 9.9%, and 7.2%, respectively.[4] The highest prevalence rate of HIV infection has been reported from the sub-Saharan Africa (17.9%).[26]

We observed that the high HIV seroprevalence among the replacement BDs (0.32%) in comparison to voluntary BDs (0.167%). Similar results have been reported by various studies.[2],[3],[8],[9],[12],[14],[16],[18],[20],[21] Replacement BDs are usually the ones who donate blood whenever there is the requirement for blood for any of his/her family member or friend or someone from the community. Such donors are considered high risk due to several reasons: (i) They might conceal or give false information related to their medical history, (ii) they might be professional/paid BD who are donating blood in exchange for money or any other form of payment, and (iii) they are also at a higher risk of contracting certain infections due to the shared exposure to predisposing factors or environment as their family members. Thus, blood collected from replacement BDs can compromise blood safety.[27],[28]

A significant rise was noted in the overall pooled HIV seroprevalence among the Indian BDs over the past two decades, i.e., 0.28% in 1995–2005-0.35% in 2006–2015. However, due to concerted and active efforts of NACO, the prevalence of TTI's has significantly reduced over the years.[5] Trend similar to NACO has been reported by Makroo et al.,[2] Philipet al.,[7] Chattoraj et al.,[15] and Yadav et al.,[26] whereas Bhattacharya et al.[19] have reported a significant rise in HIV prevalence, but the results from this study should be interpreted with a caution as they have reported the trend of HIV prevalence over 2 consecutive years. The various reasons for declining trend of HIV seroprevalence are ban of professional/paid donors, increased awareness related to blood donation, better screening assays as well as awareness, and educational campaigns conducted by the Government of India (GoI) for the general population.[2],[5],[7],[26] We observed an increase in HIV seroprevalence over the two decades in comparison to the trend reported by NACO and above-mentioned studies.[2],[5],[7],[27] The probable reasons for this are difference in the donor selection processes, type of BDs (voluntary/replacement), window period donations, type of screening assay used, switchover from third-generation screening assays to fourth-generation assays, and/or use of CLIA. It is a well-known fact that the sensitivity and specificity of the assay generations used for screening donated blood varies, thus, influencing the overall reactivity/seropositivity rate.[29] Thus, testing of the donated blood for TTIs plays a critical role in ensuring blood safety, especially if a BD has donated blood during the window period phase.[11],[17] Therefore, the risk of TTIs for such donations is very high if serological testing is performed only. With the availability of molecular assays such as nucleic acid amplification (NAT) techniques, the risk of TTIs can be reduced to some extent.[30] The authors recommend that there is a need to ensure uniform testing standards for donated blood and combination of serological and molecular assays to improve blood safety. Cost and logistic issues are the major concerns related to the implementation of NAT as a screening assay in resource-constrained country like ours.

In our study, we also observed huge variations in HIV seroprevalence among different regions. The highest HIV seroprevalence was noted among the BDs from Western India (0.433%) followed by Southern India (0.349%), Eastern India (0.34%), and Northern India (0.276%). NACO[5] has reported a highest prevalence in Eastern and Southern India, whereas UNAIDS have reported in Eastern India with increasing trend in some states of Northern and North-eastern India.[31] The various reasons for high prevalence among these regions are low literacy rates, multiple sexual partners, unemployment, and labor migration. With continuous efforts of NACO and GoI, a decrease has been noted for HIV seroprevalence over the years.[26]

The various limitations of this meta-analysis are: (i) All the studies included were retrospective observational in nature, (ii) extensive heterogeneity amongst the included studies, (iii) incomplete date related to donor demographics such as age group, gender, route of transmission, donation type ( first time/repeat donors), education status, marital status, occupation, thus, we cannot comment upon the attributes of identifying these high risk donors; therefore, the authors cannot recommend what will be the appropriate deferral, testing, and screening strategies in these BDs, (iv) difference in the type of screening assay used, i.e., third/fourth generations or ELISA/CLIA, and (v) none of the studies commented whether any confirmatory assay was performed to rule out false positivity. Therefore, it would be difficult to comment upon the actual seroprevalence of HIV among Indian BDs. Thus, there is a need to perform further studies from more blood transfusion centers or multicentric studies focusing on these limitations will help in determining the actual burden of HIV in our donor population.


  Conclusion Top


The overall pooled HIV seroprevalence rate among Indian BDs in our study was found to be 0.32%. Despite these limitations, the authors hope that the data reported in this review might contribute in guiding further research, followed by recommendations to improve blood safety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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