Background: Without intervention, 90% of recipients transfused with HIV-infected blood are expected to become infected. While post-exposure prophylaxis (PEP) is commonly prescribed in the setting of non-occupational HIV exposures, there is very limited evidence documenting efficacy in this setting. We report the successful use of combination PEP following transfusion of HIV infected blood from a viremic donor source.
Methodology: A 12 year old girl with vaso-occlusive sickle cell crisis inadvertently received 1 unit of packed red blood cells from a donor subsequently found to be HIV-1 infected with plasma HIV RNA of 9740 copies/ml (not on antiretroviral therapy [ART]).Longitudinal testing of the patient’s plasma and peripheral blood mononuclear cells (PBMCs) was performed by commercial laboratory tests and by highly sensitive research assays with thresholds of detection down to 0.07 DNA copies/106 PBMCs and 0.4 RNA copies/mL of plasma during directly observed combination anitretroviral therapy (cART) and up to 3 months after cessation of cART. Serial HIV-1 antibody measurements were also obtained.
Results: Approximately one day after the transfusion, the patient had a positive HIV ELISA and confirmatory western blot (WB), but was negative for HIV DNA by PCR. The reactive bands on WB were identical in the donor and the recipient (GP120, GP41, GP31, P24 and P17). After prompt recognition of the infected transfusion and referral to a local medical center, she was started on tenofovir, emtricitabine, ritonavir-boosted darunavir (subsequently changed to lopinavir), and raltegravir 22 hours after the start of transfusion. She demonstrated no signs or symptoms of acute HIV infection and received 13 weeks of cART in a tertiary care center under direct observation. Longitudinal testing of HIV-1 DNA and RNA by both commercial and highly sensitive research assays was negative during and 3 months after stopping cART. HIV antibody became undetectable 7 months after the exposure.
Conclusions: We demonstrate that PEP initiated shortly after infusion of HIV-1 infected blood products can prevent HIV-1 transmission, even when exposure leads to positive HIV-1 serologies. The observation that no HIV-1 DNA or RNA has been detected in blood after stopping cART and that antibody became undetectable over time strongly suggests that PEP prevented establishment of a viral reservoir. This case also cautions that the presence of positive screening antibody reactivity immediately following exposure to HIV-infected blood products may be difficult to interpret and highlights the potential use of ultra-sensitive HIV-1 assays to guide management in this setting.