AIDS in Transfusion Recipients and Hemophiliacs in France and Other European Countries

To the Editor: The issue of human immunodeficiency virus (HIV) infection-contaminated blood and blood products has long been a major health scandal in France. While an American-made blood test for HIV became available in March 1985, French government officials delayed its approval until August 1985 so that a French test could be released first. In addition, the United States began heat-treating blood products for hemophiliacs in late 1984, a year before the French adopted the practice (1). The consequences-on a public health level-of that policy have, however, not been well quantified. In 1984, two doctors in Paris (Jacques Liebowitch and Francois Pinon) had estimated that 2,500 patients per year would have received HIV-contaminated blood in France (2,3). The computation of incidence rates of AIDS in various European countries is possible by means of the European Non-Aggregate AIDS Data Set (ENAADS) made available up to March 1994 by the European Centre for the Epidemiological Monitoring of AIDS, Paris. Data are presented for Western European countries. A few countries were not included in the present analysis, either because they reported, in the period examined, <50 cases of AIDS acquired by means of blood and its products (that is, Finland, Iceland, Israel, Luxembourg, and Norway) or did not send disaggregated data to the ENAADS (that is, Ireland). Data on Germany include cases from the Federal Republic of Germany and, up to 1989, the former German Democratic Republic. The analysis presented refers to the calendar period 1985-1993. During the years considered, registration of AIDS cases had to meet the concurrent U.S. Centers for Disease Control case definition (4,5). AIDS cases were classified as hemophilic or transfusion-associated if these modes of exposure were mentioned in the AIDS report in absence of male homosexual contact and intravenous drug injection. For transfusion recipients, however, the absence of heterosexual contact with a person who had such exposures or was known to be HIV-infected was an additional requirement. Resident population estimates generally based on official censuses were obtained from the World Health Organization (WHO) database. AIDS incidence rates were computed from the number of registration cases and resident population estimates. Rates were age-standardized by the direct method, on the basis of the world standard population (6). To correct the reporting delays (that is, the lag time between the date of AIDS diagnosis and AIDS case report), the method described by Rosenberg (7) was used for the last 20 three-month periods (5 years). Additional details on the procedure used are presented elsewhere (4,8). The size of the transfusion-related AIDS epidemic up to 1993 can be derived from Fig. 1, where incidence rates for AIDS in France and other Western European countries are compared. France showed in 1985-1993, in both genders combined, the highest rate of blood-borne AIDS (3.2/1,000,000 per year) in Western Europe, 50% higher than in the second highest-risk country (Spain) and ≈3-fold higher than in the other countries, whose rates were generally close to 1/1,000,000. In 1991-1993, France had a yearly rate of transfusion-related AIDS of 3.8/1,000,000, followed by Spain (2.6) and Portugal (1.9). All other Western European countries had incidence ranging between 1.4 (Greece) and 1.0 (Germany), except the Netherlands (0.8) and Sweden (0.5). In terms of absolute figures, the estimated cumulative numbers of AIDS cases (corrected for delayed notification) among recipients of transfusions or blood products were 1,927 in France (6% of the total), followed by Spain (794, 3%), Germany (687, 6%), the United Kingdom (541, 6%), and Italy (501, 2%). The burden of HIV-contaminated blood seems to have been especially heavy on recipients of transfusions, who accounted for 78% of AIDS cases associated with blood or blood products in France. Corresponding proportions were 62% in Portugal, 54% in Italy, 37% in Germany, 34% in Spain, and 19% in the United Kingdom. With respect to hemophiliacs, more than one-eighth of the ≈3,000 hemophiliacs listed in France have been reported to have developed AIDS. Of course, the proportion of patients with AIDS who were contaminated prior to January 1985 [98% according to French government figures (1)] remains unknown. Figure 2 shows trends over time for both genders in countries with >100 cases. Incidence rates of blood-borne AIDS peaked in France in 1988-1990. Major upward trends were observed over the last 3 years in Portugal and Italy, due to the most recent spread of the AIDS epidemic in Southern Europe (4). Spain, albeit close to Italy and Portugal with respect to trends of all AIDS cases (4), shows a similarity with France with respect to trends of blood-borne AIDS. The reason for this similarity may deserve further investigation. Assuming that the excess of blood-borne AIDS observed in France, mostly in the late 1980s and early 1990s, is attributable to the different policy of management of blood and blood products, as compared with other European countries, >1,200 AIDS cases may be related to such policy in France up to 1993. The ultimate size of this epidemic remains still undetermined, but it is likely to reach 2,000-2,500 AIDS cases. Acknowledgment: We thank the national correspondents of all the countries who provided data for the European Non-Aggregate AIDS Data Set, version AIDS9403.DAT, prepared by the WHO-EC European Centre for the Epidemiological Monitoring of AIDS, Paris. This work was supported by two grants from the Ministero della Sanità-Istituto Superiore di Sanità, VII Progetto AIDS contracts 9303.12 and 9303.31, and, in part, by a grant from the European Union on STD patterns as sentinels of AIDS. *†C. La Vecchia; ‡L. Dal Maso; ‡S. Franceschi; ‡D. Serraino *Istituto di Ricerche Farmacologiche “Mario Negri”; Milan, Italy; †Istituto di Statistica Medica e Biometria, Milan, Italy; ‡Servizio di Epidemiologia; Centro di Riferimento Oncologico; Aviano (PN), Italy.FIG. 1: . Total number and age-standardized incidence rates per million population of AIDS acquired through blood or blood products in Western European countries (adjusted for reporting delay), 1985-1993.FIG. 2: . Trends of annual incidence rates of AIDS acquired through blood or blood products, by year period in some European countries, 1985-93.