HIV Prevention Knowledge Base
Biomedical Interventions: Blood Safety and Availability
Blood Donors in Kenya: A Comparison of Voluntary and Family Replacement Donors Based on a Population-based Survey
A cross-sectional, nationally representative AIDS survey in 2007 was used to compare voluntary blood donors with family replacement donors (FRD) in Kenya. Nearly 18,000 men and women aged 15 to 64 years participated, providing blood samples that were tested for sexually transmitted infections. Approximately 2 percent (445) had donated blood in the year before the survey. Among them, the majority reported voluntary donation (64 percent). Volunteer donors tended to be younger and wealthier than FRDs and reported lower levels of sexual activity and fewer sex partners in the year before the survey. HIV prevalence was 2.6 percent among voluntary donors and 7.4 percent among FRDs (p = 0.07); herpes simplex virus 2 prevalence was 20 percent and 40 percent, respectively (p = 0.001). Voluntary donors comprised 6.5 of every 10 blood donations in 2007, up from 2 in 10 in 2001. Efforts are needed, however, to reduce reliance on FRDs, who are generally subject to less stringent screening practices and thus increase the risk of TTI.
Reduced Risk of Transfusion-transmitted HIV in Kenya through Centrally Co-ordinated Blood Centres, Stringent Donor Selection and Effective p24 Antigen-HIV Antibody Screening
Kenya began implementing measures to reduce transfusion-transmitted infections (TTIs) in its national blood supply in 2001. Donations are voluntary and non-remunerated, and donors undergo a health exam and answer a behavioral risk screening questionnaire. Donations are also screened using fourth-generation p24 antigen and HIV 1 and 2 antibody tests (ELISA). Such screening is not likely to detect infections within the window period before seroconversion, which is approximately 18 days. Nucleic acid testing (NAT) can reduce this window period to about 11 days. To estimate the number of window period infections entering the Kenyan blood supply, over 12,000 specimens from six national collection centers were tested for HIV using NAT. Any additional positive HIV donations in this sample would be attributable to the limitations of the fourth-generation screening tests. NAT retesting found no additional HIV infections, indicating that ELISA screening can significantly reduce HIV in the nation’s blood supply, even in a setting with a generalized HIV epidemic. Because NAT costs 3 to 10 times more than ELISA, low-resource countries should carefully weigh the advantages and costs of using NAT.
The Risk of Transfusion-transmitted Infections in Sub-Saharan Africa.
This paper presents the first published modeling estimates of transfusion-transmitted infections (TTIs) in 45 sub-Saharan African countries. Despite a lack of data for 28 countries, the authors used available data, multiple assumptions, and applied statistical techniques to obtain rough risk estimates. With the current rate of 2 million annual transfusions in the region, the risk of infection with one unit of blood is 1.0 in 1,000 for HIV, 4.3 in 1,000 for hepatitis B, and 2.5 in 1,000 for Hepatitis C, resulting in nearly 16,000 TTIs. If the total estimated 6.65 million needed transfusions took place each year, the total annual TTIs would increase to nearly 52,000. Country-level data for 16 countries with more complete data find risks ranging from 7 HIV infections per 100,000 donations in South Africa to 1,096 hepatitis C infections per 100,000 donations in Gabon. A more thorough understanding of TTI risks can help countries develop appropriate responses. Because the disease burden of TTI is so high, the authors “reiterate the need for increased support from the global community to address transfusion-associated risks in the region.”
HIV Transmission through Transfusion—Missouri and Colorado, 2008
This case report documents the rare event of HIV transmission via blood transfusion in the United States. After testing negative for HIV, a regular donor’s blood was transfused to two patients. On repeat donation several months later, this donor’s blood tested positive. Thus, the first blood donation took place during the window period, before the donor seroconverted. One recipient of the infected blood died due to underlying disease, and the second was indeed infected with HIV. The authors estimate that if 16 million blood donations take place annually in the United States, there are likely to be 11 infectious donations, resulting in 20 infected blood components. The questionnaire given to potential blood donors screens high-risk people out of the donation process. In this case study, the infected donor admitted to not answering truthfully to the screening questions. People who donate blood must answer accurately for the screening mechanism to work, thus reducing the risk of such window period infections entering the blood supply.
The Blood Donor in Sub-Saharan Africa: A Review.
Although voluntary, regular, non-remunerated blood donors (VNRD) form the “backbone” of a healthy blood supply, most transfusions in sub-Saharan Africa are done through family replacement donations. In some countries, as much as 70 percent of the blood supply comes through such donors; voluntary donors were found to represent less than half of blood donors in 15 of 38 countries in one study. VNRD tend to be male and younger, and the authors describe successful strategies for recruiting and retaining such donors in Ghana and Zimbabwe. The review includes estimates of HIV, hepatitis B, and hepatitis C prevalence among repeat donors and first-time donors for 15 countries whose blood supply is comprised primarily of VNRD. The high prevalence of infectious disease in the region necessitates a strong blood screening program. This is a significant challenge, however, given infrastructure, financing, and cultural constraints in the region. The authors state that “more effort is required in the drive for education, motivation, and recruitment of regular donors,” and conclude that collaborating with international partners may be the key to making it happen.
WHO Global Consultation: 100% Voluntary Non-Remunerated Donation of Blood and Blood Components
This document resulted from a global consultation meeting held in Melbourne, Australia, in 2009 that reviewed current barriers to safe global blood supply and identified ways to help countries reach the goal of 100 percent voluntary, non-remunerated blood donation. Country-specific examples illustrate the key issues and challenges of implementing such a policy, such as the role of the government and raising and maintaining public awareness. The document includes a copy of the Melbourne Declaration, which calls on WHO member states to achieve 100 percent voluntary, non-remunerated blood donations by 2020, and a checklist for action to achieve this.
Universal Access to Safe Blood Transfusion
This report looks both globally and regionally at the obstacles to universal access to safe blood transfusion. It then describes the key elements of eight strategies and approaches to help reach this goal. These include achieving totally voluntary, non-remunerated blood transfusion; universal access to safe blood donation; optimal use of donated blood; work force development; and developing quality transfusion management systems. The report also outlines WHO’s Global Strategic Plan for Universal Access to Safe Blood Transfusion, 2008–2015 and lays out recommendations for WHO, national health authorities, and national or regional blood transfusion services (BTS).
Reducing Replacement Donors in Sub-Saharan Africa: Challenges and Affordability
This review found that the cost of voluntary blood donation at centralized collection centers is up to eight times higher than replacement collection at the hospital level, raising concerns about the sustainability of the centralized model in resource-poor settings. In practice, many countries incorporate elements of national coordination into locally based collection services and also use a variety of funding models according to local circumstances. The review cites sub-Saharan African examples of innovative strategies to collect and efficiently utilize donated blood. It also highlights the need for more data on the cost-effectiveness of hybrid strategies and research into their replicability in other countries.
Financing Blood Transfusion Services in sub-Saharan Africa: A Role for User Fees?
Given the high costs of protecting a nation’s blood supply, country budget constraints, and high levels of HIV, these researchers model multiple scenarios to understand whether levying user fees on blood recipients is a feasible way of financing blood transfusion services (BTS) in sub-Saharan Africa. The authors first undertake a literature review and detail the BTS in Côte d’Ivoire, Mozambique, and Zimbabwe, including financing. BTS expenditures were estimated at 0.8 percent of total public health expenditure in Côte d’Ivoire, 1.5 percent in Zimbabwe, and, for comparison purposes, 0.5 percent in England. Different scenarios are posed for collecting user fees, including three institutional funding options (fully central budget–funded, fully hospital-funded, or mixed) and five patient payment options. The authors present strengths and weaknesses of each scenario, concluding that there is a “limited role” for user fees in these settings. They summarize five key lessons learned from the costing exercise for program planners and donors to consider.
Monetary Blood Donation Incentives and Risk of Transfusion-Transmitted Infection
This study compiles the findings of numerous studies comparing infectious disease markers in blood from paid versus volunteer donors and finds that there is an association between paid donation and higher prevalence of donor HIV, hepatitis B and C, and syphilis infection as well as higher incidence of transfusion-transmitted infections (TTIs). However, the author acknowledges that many of the studies were small, not well controlled, and lacked statistical significance testing. Although it can be difficult to eliminate reliance on paid blood donors, the author writes, educational programs and government policies have helped overcome economic and cultural barriers to 100 percent voluntary, non-remunerated blood donation in many countries.