Table 1 lists the demographic characteristics of the sample stratified by HIV status. More women participated in the survey than men, with a female-to-male gender ratio of 2.0 (1331/666). Men had a higher prevalence of HIV than women (15.8 versus 8.3%). Participants who had been employed or sought employment elsewhere in the past year had a higher HIV prevalence than those who did not.
There was no significant difference in HIV prevalence according to marital status, age, having extra jobs, or education level. Different townships had different rates of HIV prevalence, ranging from 5.7 to 21.6%.
HIV risk characteristics
Comparisons of HIV risk characteristics between HIV-positive and -negative subjects were conducted (Table 2). The history of blood and/or plasma donation, total number of plasma donations, spouse's HIV status, having more than one sexual partner, and total number of blood donations were significantly associated with HIV infection. Condom use was not associated with HIV infection, but was infrequent (ever having used a condom was 5.9%, and consistent condom use was only 1.1%).
Correlates for HIV infection
Donating both blood and plasma (OR, 5.91), donating plasma only (OR, 5.74), having an HIV-infected spouse (OR, 6.56), having multiple sex partners (OR, 3.37), male gender (OR, 1.81), and place of residence (OR, 2.08, township 2 versus township 6, the reference township) (Table 3) were significantly associated with HIV infection according to multivariate logistic regression.
Number of plasma/blood donations
When the total number of plasma and blood donations was used in the model, multivariate logistic regression analysis showed the same variables were associated with HIV infection as in the above model (Table 4). The more plasma donations made, the higher the risk of HIV infection (OR, 8.81 for participants who donated plasma more than 10 times; OR, 3.01 for those who donated plasma 4–9 times; and OR, 2.26 for those who donated 1–3 times). Number of blood donations was not associated with HIV infection, and after controlling for other variables, blood donation history was also not associated.
Correlates of HIV infection among plasma donors
Among plasma donors, the following variables were significantly associated with HIV infection after adjusting for other potential confounders: number of plasma donations (OR 4.09 for subjects who donated plasma more than 10 times), spouse being HIV-positive (OR, 4.06), and male gender (OR, 2.04). Having multiple sexual partners was marginally associated with HIV infection (OR, 2.37; P = 0.097).
Correlates of HIV infection among non-plasma donors
Factors that were significantly associated with HIV infection among non-plasma donors after adjusting for other variables were spouse being HIV positive (OR, 11.07) and having multiple sexual partners (OR, 7.04) (Table 5). Gender was not associated with HIV infection among non-plasma donors. Condom use was rare, and none of the HIV-positive participants had used condoms in the past year, precluding analysis of correlates.
This survey revealed that the prevalence of HIV infection was 10.8% among rural residents in villages with many FPDs in rural Anhui, China. Amongst FPDs, the prevalence was 15.2%. For residents without a history of plasma donations, the prevalence was 4.9%. Both were higher than in a previous survey done in 1996 in the same area (12.5% among FPDs and 2.1% among non-donor spouses) . Yan et al. found the HIV prevalence was 25.9% among FPDs in another county in 1999 . Zheng et al. found the HIV prevalence was 17.0% among FPDs and 0.2% among non-plasma donors in another county in 2000 . The latter two studies had a smaller sample size of plasma donors. It is clear that HIV is now spreading beyond the FPD population, which is a cause for alarm.
HIV prevalence was associated with both a history of plasma donations and total number of plasma donations. The above-mentioned studies also showed the same relationship. This indicates that plasma donation 8–9 years ago was the major cause of the current HIV/AIDS epidemic in rural China. However, this study also clearly demonstrated that donating blood did not put donors at risk of HIV infection.
It was surprising that men had a much higher prevalence than women (15.8 versus 8.3%). The possible explanations may include but are not limited to the following factors: (1) more healthy (that is, more HIV-negative) men migrated out for jobs; and (2) more HIV-infected women died than men because the natural history of HIV infection is shorter in women than men [11–13].
Nearly 5% of non-plasma donors were found to be HIV-positive, suggesting that HIV has spread from FPDs to the general population. The multivariate logistic regression analysis conducted for the total sample, subgroups of plasma donors, and non-plasma donors all showed that a spouse being HIV-positive and having multiple sexual partners were associated with HIV infection. These indicated that HIV secondary transmission through sex is occurring in the area, both within the marriage (spouse being HIV-positive) and outside of marriage (multiple sexual partners). This spread is enhanced by low rates of condom use. Therefore, condoms should be promoted urgently to prevent further spreading of the virus through sex. Condoms must be used not only for extramarital sex, but also within marriage, especially by HIV-discordant couples. Consistent condom use should be emphasized in rural areas, because it is different from the information provided to them for the purpose of family planning.
HIV voluntary counseling and testing (VCT) should be promoted, both because free antiretroviral treatment is becoming available in these areas affected by HIV through plasma donation in China, and because knowledge of HIV status reduces risk behaviors [14–16]. Without knowledge of their HIV status, infected individuals will not seek the treatment they need and are unlikely to reduce their risk behaviors.
The difference in HIV prevalence between this and the previous study among FPDs in the same areas (15.2 versus 12.5%) and non-plasma donors (4.9 versus 2.1%) may indicate a true increase, due to sexual transmission that occurred after the first survey, nosocomial transmission that occurred after the first survey, and/or different migration rates between HIV-positive and -negative villagers. We reason that the difference probably includes all four, but sexual transmission probably accounts for the majority of the difference, given that having an HIV-positive spouse and/or having multiple sexual partners were both strongly associated with HIV infection.
There are several limitations in this study. First, many local rural residents temporarily migrate to urban areas. In this study, there were many more female than male participants, yielding a gender ratio of 2.0, so this sample was not representative of all the rural residents. Given the fact that the HIV/AIDS epidemic started in early 1990s and the average incubation of HIV/AIDS is 9 years or less, people infected with HIV were more likely to stay at home. If this were the case, the prevalence of HIV infection identified by this study might be higher than true prevalence. Second, all variables except for HIV status were self-reported; thus, some sensitive information could be under-reported, such as extramarital sex. A study using tape recorder and earphones to administer questions in the same area indicated a higher rate of extramarital sex (7.8%) . If some FPDs reported being non-FPDs, the HIV prevalence would be overestimated among non-FPDs and underestimated among FPDs. Given the fact that blood/plasma donation was common in the area, this reporting bias is likely to be low. Third, nosocomial transmission of HIV infection was not assessed in this study. Given the low rate of compliance of universal precautions in rural Anhui , nosocomial transmission of HIV is likely to occur. A previous study found that a history of invasive medical care was not associated with HIV infection . Nonetheless, the magnitude of nosocomial HIV transmission should be assessed in future studies.
The HIV/AIDS epidemic has been introduced from FPDs into the general population, which is a very disturbing observation that does not auger well for the future of the HIV epidemic in China, unless dramatic action is taken immediately.
The factors associated with HIV infection are frequency of plasma donations, spouse being HIV-positive, having multiple sexual partners, and residential location. Thus, both plasma donation and sexual transmission were responsible for the current HIV/AIDS epidemic among adults in the area.
Since condom use is low, HIV-infected villagers have multiple sexual partners, and villagers frequently migrate to urban areas to look for jobs, it is likely that HIV will continue to spread both in the local areas and in the urban areas to which villagers temporarily migrate.
Condoms should be promoted urgently for both intra- and extramarital sex to prevent further spreading of the virus through sex in rural China. HIV VCT should be promoted, especially as antiretroviral treatment is becoming available in these areas affected by HIV in China.
We thank Wendy Aft of the UCLA School of Public Health for her assistance with preparing the manuscript.
Sponsorship: This research was supported by the Fogarty AIDS International Training and Research Program (D43 TW000013).
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Keywords:© 2006 Lippincott Williams & Wilkins, Inc.
HIV/AIDS; former plasma donors; China; HIV transmission