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SAIDS and the Blood Supply The advent of AIDS and HIV infection has raised new concerns about the safety of the blood supply in the United States. Although safety has been a concern since the beginning of the era of transfusion medicine and is not unique to the AIDS epidemic, the stresses that AIDS places on the blood supply pose serious challenges to those charged with protecting that supply. These challenges will require not only the continuing efforts of the blood banking system, which is responsible for protecting the supply, but the intervention of both the biomedical and the social/behavioral research communities to devise strategies that address three major areas of concern: (~) maintaining an adequate supply of safe blood; (2) ensuring the safety of that supply; and (3) encouraging appropriate use of blood and blood components. Infectious diseases are of paramount interest to those responsible for protecting the blood supply, but maintaining an adequate supply of safe blood has become increasingly important as the donors who provide that supply receive more scrutiny. Only a small fraction of the people who may be eligible attempt to give blood, and those who do are requiem to meet increasingly stringent criteria designed to protect blood recipients. If eligibility cr~tena become even more stringent and the donor pool is not enlarged, the supply will inevitably contract. The demand for blood in this country is substantial but not without some flexibility, as noted in the discussion of the appropriate use of blood at the end of this chapter. Each year, more than 4 million patients receive approximately 20 million tin 1986 only a small minority of the age-eligible donors~.6 percentdonated (Linden, Gregorio, and Kalish, 1988); repeat donors constituted an even smaller proportion. 289
290 ~ AIDS: THE SECOND DECADE transfusions of blood or blood components (red blood cells, platelets, leukocytes, or plasma) prepared from about 12.5 million units2 of blood. Of the 20 million units used, a significant number may be transfused unnecessarily.3 In the era of AIDS, the question of the inappropriate use of blood has come under renewed examination as the balance between supply and demand becomes increasingly precarious. Although maintaining an adequate supply of blood is crucial to the delivery of health care, a great deal of concern has also been expressed about the safety of the blood that is being donated. Technological ad- vances provide increasingly expanded capacities to detect evidence of infectious pathogens in the blood itself, but in the case of AIDS the time lag between acquisition of HIV infection and the production of antibodies highlights the limitations of technology to solve all of the problems AIDS brings to blood. Thus, technological solutions must be augmented by behavioral strategies that focus on donor character~stics- who the donors are and whether they engage in behaviors that may have put them at risk for acquiring HIV infection and emphasize approaches that identify, recruit, and retain only those donors who are least likely to be infected. After 1975, the blood collection system in the United States ceased outright payments, except in a few cases, for the donation of whole blood.4 Studies of viral hepatitis demonstrated that the rate of this infection was greater In recipients of blood from paid donors than In recipients of blood from volunteers (Walsh et al., 1970; Alter, Holland, and Purcell, 1975; Seeff et al., 1975; Alter, 1987~. An all-volunteer system was established to prevent the intrusion of undesirable factors (e.g., financial remuneration) into motivations to donate blood. Yet the question of safety does not stand alone. Indeed, shortages, which have been apparent in some areas of the country for some time, reemerge as a continuing problem that now warrants additional attention. Thus, the issues of adequate supply and safety are integrally connected. In this chapter, the committee looks at how blood is collected, how the balance between supply and demand can be maintained through in- tervention strategies targeting the donors that supply the blood and the physicians that prescribe its use, and behavioral mechanisms to protect 2A unit, which is the standard donation per individual, is generally 450 milliliters, and each unit is, on the average, converted to 1.54 component units (summing et al.? 1989). 3 Christine Parker, National Heart, Lung, and Blood Institute, personal communication, February 15, 1990. 4Donors with rare blood types may be paid to provide a regular supply of this scarce resource, and a few blood collection organizations (e.g., The Mayo Clinic) provide payment for at least a portion of their regular donors, though this practice is being phased out.
BLOOD SUPPLY ~ 291 the safety of the blood supply. Because of the connection between an adequate and a safe blood supply, the committee has grouped its recom- mendations concerning these issues after its review of related substantive material. BRIEF HISTORY AND OVERVIEW OF THE PROBLEM Early in the epidemic, suspicions arose that AIDS could be transmitted by transfusion (CDC, '982; Curran etal., 1984~. In the spring of 1983, cases of AIDS diagnosed among hemophiliacs were thought to be related to clotting factor concentrates made from contaminated blood (Evatt et al., 19831. Although the etiologic or causative agent of AIDS had not been identified in the early 1980s and no specific diagnostic tests were available, reports of cases among transfusion recipients and hemophiliacs prompted blood banks to institute a variety of procedures to reduce the risk of AIDS associated with blood transfusions. Such procedures included efforts to exclude donors who were members of groups at high risk for the disease, studies of the use of tests that measured factors considered to be surrogate markers of AIDS (e.g., antibody to hepatitis B core antigen, T-lymphocyte ratios), the increased use of autologous donation (providing one's own blood for personal use), and the reduction of unnecessary transfusions of blood and blood components (Nichols, 1986~. After the etiologic agent, HIV, was identified and blood tests for . . antibody to the virus became available in March 1985, blood collec- tion organizations added this serologic test to their screening procedures (CDC, 1985; Ward et al., 1986~. Yet despite the high sensitivity of HIV antibody tests, they do not detect all infected donors (CDC, 1986; Ward et al., 198Sb). A variable length of time elapses between acquisition of the virus and development of a detectable antibody response. Generally, this period is no more than a few months, but in one study virus was isolated from blood samples of 27 men who did not yet exhibit antibod- ies for periods of as long as three years after the initial positive virus culture (Imagawa et al., 19891. Dunng this so-called "window" period, the blood collected from an infected donor may test negative and thus go undetected by the serologic screening mechanisms employed in most blood banks.5 The current incidence of HIV infection from antibody-negative blood in the United States is not known. Estimates vary from a rate of approx- imately one infection for every 40,000-50,000 units transfused (N. D. S Although evidence of infection can be demonstrated among antibody-negative individuals during the window period, the precise risk associated with transmission during this period is not known.
292 ~ Alas: THE SECOND DECADE Cohen et al., 1989) to one in every 153,000 units transfused (summing et al., 19891.6 Estimates of the prevalence of detectable HIV infection in donors have ranged from 1.3 to 5 per 10,000 (Ward et al., 1988a; Hughes et al., 19891. These rates, however, are not constant across all donor groups, geographic areas, or time. For example, seroprevalence rates are higher among black and Hispanic donors and among younger males (Ward et al., 1988a; Hughes et al., 19891. It also appears that repeat donors, especially females, are less likely to be infected than are first-time donors (summing et al., 1989; Leitman et al., 19891. The proportion of HIV antibody-positive donations has also decreased over time. This decrease is due both to notification and exclusion of donors found to be positive for antibody to HIV and to success in donor self- exclusion measures, donor prescreening, community education efforts, availability of HIV antibody tests in alternative sites for donors who have been using blood collection systems for this service, and a reduction in the incidence of new HIV infections in some populations (Ward et al., 1988a; Hughes et al., 19891.7 Nevertheless, the risk of HIV transmission through transfusion remains (Kleinman and Secord, 1988; N. D. Cohen et al., 1989~. Although HIV antibody tests cannot eliminate all possibility of transfusion-associated HIV infection, Hey have vastly improved the safety of the blood supply. Additional methods to detect infected units, such as those based on recombinant-DNA technology, synthetic peptides, and gene-amplification techniques, are being explored to increase the sen- sitivity of serologic testing (Menitove, 1989~. Other safeguards involving improved donor screening and recruitment are also being evaluated and implemented as described below. 7 THE BLOOD COLLECTION SYSTEM IN THE UNITED STATES hn the United States there are two separate systems that collect blood for various products: (1) a commercial system that pays donors for plasmas 6Cumming and colleagues (1989) report a range of one infection in 88,000 units transfused to one in 300,000. Earlier in the epidemic, Kleinman and Secord (1988) estimated that the risk of infection from blood that tested negative for HIV antibody was between one in 51,000 units to one in 102,000 units. The lower rates of infection associated with antibody-negative donations that have been derived from more recently collected data may reflect diminishing numbers of HIV-positive donors and a changing donor pool that may include more tested donors (Menitove, 1989). 7It should be noted that before testing was available, self-exclusionary and prescreening measures resulted in significant deferral rates among gay men (Wykoff and Halsey, 1986). 8 Plasma is the fluid component of blood that transports water, nutrients, minerals, oxygen, and hor- mones to all cells of the body. It also contains important proteins and other substances vital to the clotting capacity of blood and to maintaining the integrity of the circulation. Plasma collected from
BLOOD SUPPLY | 293 used by industry to manufacture albumin, antihemophilic factor, gamma globulin, and various protein derivatives; and (2) a voluntary system for whole blood that uses no monetary incentives to motivate donations. This latter system provides whole blood and blood components such as platelets, red blood cells, cryoprecipitate, and plasma for blood trans- fusion services. Plasma that is not used for transfusion is provided to pharmaceutical companies for the manufacture of blood products. This report deals only with the voluntary system for whole blood collection. The volunteer donor system expects healthy individuals to donate blood to meet the needs of their community; those who need blood then receive it at the cost of collection plus processing. Occasionally, individuals make directed donations, donating blood specifically for use by friends or relatives. Before the AIDS epidemic, enough volunteers gave blood to maintain an adequate supply for most parts of the country although only 5 or 6 percent of the adult population donated blood in any given year. Today, however, there is not enough blood available locally in several U.S. communities, and in such cases blood must be acquired from individuals in other locales. The Organization of Blood Collection There are three major blood collection organizations operating at the community level: the Amencan Red Cross, the American Association of Blood Barks (AABB), and the Council of Community Blood Centers (CCBC). The American Red Cross currently collects about half of the blood used in the United States (Kalish, Cable, and Roberts, 1986~. The AABB and the members of the CCBC and independent hospital blood banks collect the remainder. On the United States, approximately 80 percent of donated blood is collected at mobile sites through blood drives that recruit donors from organizations such as high schools, universities, businesses, and corporations of wearying size, as well as the offices of local governments and other public-sector organizations. Equipment to collect blood is brought to the donors, either through a bloodmobile van or in temporary facilities set up at the donors' organization. Blood is also collected at fixed sites (e.g., buildings that house the necessary equipment and staff on a permanent basis). Individuals who come to donate on their own initiative may prefer fixed sites, although few studies link different subpopulations of donors to donation sites. Thus, it is not clear that fixed sites and mobile operations are dealing with the same donor populations. paid donors in the commercial system is treated with detergents or heat to kill infectious pathogens, including viruses (Horowitz, 1987). Thus, the danger of acquiring HIV infection from these products is greatly reduced.
294 ~ AIDS: THE SECOND DECADE Once the blood has been collected and tested for a variety of infec- tious agents Concluding HIV), those units that pass all safety requirements are distributed to blood banks and organizations that transfuse blood and blood products, such as hospitals and dialysis centers. The shelf life of blood and blood components ranges from 72 hours to 42 days, depending on the specific component. However, frozen products can generally withstand longer periods of storage than fresh ones, although some components (e.g., platelets) cannot be frozen. Exclusionary Procedures Donor deferral measures have two goals: (1) to protect the donor from potential harm and (2) to ensure the safety of the recipient. People are deferred from donation, either temporarily or permanently, for a number of reasons, including fever, anemia, a history of exposure to malaria, recent infection, signs of symptoms of HIV infection, or a history of r~sk-associated behavior. Blood banks have established procedures to assist potential donors in their assessment of whether they may have been exposed to HIV and to discourage those at risk from donat~ng.9 Each donor is given information about the donation process and about infections transmitted by blood, especially HIV, and asked to read it carefully. Those who have signs or symptoms of AIDS or who have engaged in behaviors that put them at risk are asked not to donate (self-defer) and are informed that they may leave the donation site with no explanation required. Potential donors who choose to continue the donation process provide a confidential health history, which is given to or reviewed by a member of the blood collection staff. (Donors are asked a number of health-related questions, including questions about possible exposure to HIV and symptoms consistent with HIV-related illnesses.) Following the health history, donors are asked to attest that they have read and understood the information about risk factors for AIDS. Because some potential donors fee} pressure to donate blood (es- pecially during blood drives) and others may not have been truthful in responding to questions posed during the health history, all donors are offered yet another opportunity to exclude their unit from the blood sup- ply even if they complete the donation process. The donor is asked to choose one of two options for handling the unit of blood indicating either that (1) the blood may be used for transfusion or (2) the blood should not be transfused. Donors select the option in private or using a code so 9Minimum donor guidelines for exclusionary criteria have been established by federal regulatory law, but additional restrictions can be imposed by blood collection organizations (Linden, Gregorio, and Kalish, 1988).
BLOOD SUPPLY ~ 295 that others in the blood collection facility will not learn of the choice. This step is referred to as confidential unit exclusion, or the CUE. Some centers also use a callback system that permits donors after leaving the site to notify the blood bank that they may be at risk. Regardless of subsequent laboratory test results, all units identified by the donors for exclusion from transfusion are removed from the blood distribution pool. This step allows a donor to go through the entire donation process in the presence of friends and associates without revealing potentially sensitive inflation and without compromising the safety of the blood supply. Exclusionary Procedures: The Organizational Perspective Although donors who may be at risk of acquiring HIV infection are discouraged from donating and are given an opportunity to have their blood discarded through self-exclusion mechanisms, these approaches are by no means fully effective. The majority of donors who are found to be HIV antibody positive do not self-exclude. Thus, continuing efforts are needed to improve approaches for discouraging HTV-infected individuals from giving blood and to educate potential donors more effectively to improve self-exclusion. In this section, the committee looks at how the organization of blood collection might affect donor deferral and proposes structural changes that may improve this process. In a later section of the chapter, the committee reviews the impact of exclusionary measures on donor behavior. Generally, AIDS-related information is only provided to prospective donors when they a:Tive to give blood. It may also be productive to contact individuals before they come to donate and provide specific information about behaviors that exclude donors. This practice would allow prospective donors time to reflect on their risk status and to make decisions regarding donation in private and under conditions of lower social pressure. In setting the tone for such information, blood collection organizations should stress both the factors that motivate donors to give (which are described below) and the altruistic reasons for not donating if at risk. It should be made clear that appropriate self-deferral is a community-spirited act. There are other informational issues that blood collection organiza- tions must consider. In addition to providing AIDS-related information, community blood centers may wish at this time of increasing fear and decreasing supply to increase their efforts to educate the public regarding blood donation in general. Such efforts should tap a broader range of individuals and organizations and make more effective use of coordina- tion. The media can also play an important role in providing messages
296 ~ AIDS: THE SECOND DECADE about the need for blood, the need for specific individuals to give, the safety and ease of giving, the collective responsibility for the quality and quantity of the blood supply, and the problems associated with alternative collection systems (such as directed and paid donation). One approach to improving self-deferral, albeit a controversial one, has been the use of direct questions concerning intimate personal be- havior. In August 1989, the American Association of Blood Banks took the tradition-breaking position that donors should be asked specific ques- tions regarding risky behaviors during the health history. Although the presumption had been that donors would not be likely to answer such questions honestly, recent studies suggest that direct questioning may be more effective than previously thought in identifying high-nsk donors. Silvergleid, LeParc, and Schmidt (1989) found that 90 percent of donors approved of direct questioningly and that direct (as opposed to indirect) questioning resulted in a fivefold increase in deferrals for participation in high-nsk activities. Although the Food and Drug Administration (FDA), one of the federal institutions responsible for regulating the blood collec- tion system in this county, has provided recommendations concerning the provision of educational materials to donors, to date no guidelines have been developed concerning direct questioning of potential donors during the health history. The use of explicit questions during the donation process can create problems related to loss of privacy and confidentiality if one donor can overhear the questions asked and answers given by another. This problem would be most severe in small bloodmobiles or in an instance in which a donor knows others who are giving blood at the same time. Thus, if interviewing is to be effective in eliciting truthful responses to direct questions on sensitive matters, the physical settings in which interviews take place must take privacy into account. One possible solution might be computer-conducted health history interviews, which afford privacy even when space is limited. Computer questioning may also eliminate embarrassment on the part of both interviewer and interviewee when sensitive topics are covered and might lead to greater honesty in reporting risk behaviors. However, the capacity of donors to understand written material and to use computers must be kept in mind when developing such an interview format. Changes in the "processing" of donors raise staffing issues for blood collection organizations. Increased scrutiny of potential donors involves a more detailed history and currently relies on a face-to-face interview Wholly 1 percent of donors found the questions to be embarrassing, and only 1 percent said Hey would stop donaimg blood because of explicit questioning (Silvergleid, LeParc, and Schmidt, 1989).
BLOOD SUPPLY ~ 297 concerning behaviors that may be stigmatizing or even illegal. Expe- rience from survey research involving personal interviews shows that adequate interviewer training improves the quality of the data that are collected (Hymen et al., 1975; Fowler, 1989; Fowler and Mangione, 1990; Campbell et al., n.d.~. Studies of sexual behavior have revealed that even experienced interviewers require special training to gather valid data on sensitive topics (Reinisch, Sanders, and Ziemba-Davis, 19881. Blood collection staff who are not professionally trained in discussing sensitive personal issues may fee] uncomfortable and therefore may not be very effective in this area. Specific training may help these staff over- come this battier or identify those who should not be entrusted with this task. Processing donors raises the difficult issue of managing donors who must be deferred. Donors who are temporarily or permanently deferred require careful attention from staff. Donors who are permanently deferred must be made to understand that they should not give blood again. However, donors who are temporarily deferred may be eligible to donate in the future and, in the interest of securing an adequate supply of blood, these donors should be effectively encouraged to return at an appropriate time. Because little is known about the factors associated with successful management of permanent or temporary deferral of donors, this topic could benefit from additional research. Although organizational issues may be important in fine-tuning donor screening to maintain a safe blood supply, other issues must also be addressed. If blood banks are to reconsider how they recruit and retain sufficient numbers of safe donors, several questions need to be answered. What motivates people to donate? What are the banners to donation? What characterizes safe donors? The next section discusses available data on donor demographics and behavior and explores areas in which additional information is needed. MAINTAINING AN ADEQUATE SUPPLY OF SAFE BLOOD Given the increasing restrictions on donors, it is reasonable to question whether the number of donors will be sufficient to maintain a supply of blood that is adequate to meet current and future demands. The American Red Cross estimates that, of 14.8 million donors who presented at blood collection sites between 1986 and 1987, 1.3 million were deferred. Of 13.2 million units collected, 0.7 million were rejected at the time of testing (summing, Schorr, and Wallace, 1987~. The impact of exclusionary policies on the adequacy and safety of the blood supply remains an important area of study, although existing data indicate increasingly lower
298 AIDS: THE SECOND DECADE rates of HIV antibody-positive donations over time. These data also show significant decreases in the number of high-nsk donors, especially males. As more donors are deferred and as more donations are rejected, the issue of supply shortages will inevitably anse. Periodic shortages are already occurring, arid some regions must ob- ta~n blood from other areas. In deciding whether or not to obtain blood from other areas during periods of shortage, administrators of blood col- lection organizations may balance the cost of more intensive recruitment efforts against the cost of getting blood from another organization. In areas win persistent shortages, management may favor purchasing blood from other areas, as recruitment efforts are very costly and may not result in a supply that will be adequate to meet the demand. Although the precise number of people whose medical or behavioral history excludes them from the pool of potential donors is uncertain, recent research suggests that more than half of the men and women in the United States should be eligible to give blood Gregory and Linden, 1988; Linden, Gregorio, and Kalish, 1988~.~3 Thus, factors other than 11In a New York area study that compared the donor population of 1982 to that of 1983, Pindyck and coworkers (1985) found that male participation in New York City decreased by 6.1 percent; the decrease was particularly striking among 21- to 36-year-old males. Medical screening resulted in rejection of 2 percent of all individuals presenting as donors at the Greater New York Blood Program and the confidential unit of exclusion (CUE) procedure eliminated another 1.4 percent. However, there was an overall increase in blood collections of 1.1 percent, largely due to increases in the participation of women and men from over areas (Pindyck et al., 1985). A review of 818,629 donations collected in three major blood centers in the United States between March 1985 and July 1986 found that 450, or 0.05 percent' were HIV antibody positive (Ward et al., 1988a). Between May 1988 and September 1989, 756 HIV antibody-positive donations (0.029 percent) were found among 2.65 million donations at 19 different blood centers (Council of Community Blood Centers, 1989). 12 Anecdotal infonnation indicates that the Irwin Memorial Blood Bank in San Francisco is encoun- tering the worst shortage of donors in its 50-year history. (See David Perlman, "Major Blood Bank Facing Worst-Ever Shortage of Donors," San Franc~sco Chronicle, February 1, 1989.) For example, normal inventory would include 350 units of type O-positive blood, but on January 31, 1989, only 9 units were available; 60 units were flown in from Milwaukee. However, the cause of this shortage is less than clear, blood bank officials indicated that flu viruses were in part to blame (see George Raine, `'Bay Area Supplies of Blood at Crisis," San Francisco Examiner, February 1, 1989). 13The eligible donor population was estimated by subtracting from the number of 17- to 7S-year-olds identified in the 1980 census the number of individuals meeting American Red Cross exclusion criteria for (1) low hematocrit levels, (2) inadequate body weight, (3) recent pregnancy, (4) heart disease, (5) diabetes requiring insulin, (6) high blood pressure, (7) male homosexual activity since 1977, (8) intravenous drug use, (9) sexual contact with a member of a high-risk group, (10) transfusion within the previous six months, (11) history of cancer, and (12) other factors, including a history of hepatitis, medications, and certain types of foreign travel. (See Linden, Gregorio, and Kalish  for criteria definition, data sources, and estimates of individuals meeting exclusionary criteria as well as estimated overlap across criteria.) The authors estimate that 57 percent of women and 70 percent of men are eligible to donate blood. Screening for hepatitis C (non-A, non-B) virus would further reduce these numbers but only slightly.
BLOOD SUPPLY ~ 299 eligibility, including willingness to give blood, play an important role in maintaining an adequate blood supply. The current challenge lies in utilizing available information on the characteristics of individuals who donated in the past and on factors that motivate people to participate to devise effective strategies for safe donor recruitment. Who Donates Blood? In the United States most blood is given by donors who have given blood before (American Red Cross Mid-America Regional Blood Services, 1980; Piliavin and Callero, in press). Epidemiological studies find that repeat blood donorsespecially repeat female donors have the lowest rates of infections transmitted through transfusion (Dondero et al., 1987; Cumming et al., 1989~. Consequently, both supply and safety issues highlight the importance of retaining safe donors once they have been identified. Prior to the AIDS epidemic most blood donors were men (Oswalt, 1977~; depending on when and where the data were collected, men constituted between 49 and 91 percent of the donor population (Boe, 1976; American Red Cross Mid-Amer~ca Regional Blood Services, 1980; American Red Cross Blood Services, Los Angeles-Orange Counties Re- gion, 1981; L~ightman, 19811. In a recent survey, ~ percent of men and 5 percent of women in the general population claimed to have given blood in the past year (Dawson, 19891. Among first-time donors, however, fe- males predominate (Mell, 1979; Callero, 19831. Because the majority of AIDS cases have been diagnosed among men, blood drives have looked to women as potential sources of safer blood. Unfortunately, fewer women than men are repeat donors, and gender discrepancies therefore become more apparent with subsequent donations (Mell, 1979; American Red Cross Mid-America Regional Blood Services, 1980; Callero, 1983; American Red Cross Greater Buffalo Chapter, 1985~. Less than a third of blood donors who have given one gallon or more are women (Mell, 1979; Piliavin and Callero, in press). A factor that may be related to the loss of women from the donor pool is low hemoglobin levels and depletion of iron stores, which can lead to temporary deferral. Unfortunately, even temporary discouragement from donation may have permanent effects. One remedy to this problem is routine provision of iron supplements to permit such women to remain regular donors (Gordeuk et al., 19871. In an experiment using "VIP" donors a special group whose members volunteer to donate at least four times a yearadministenng iron supplements to menstruating female
300 ~ AIDS: THE SECOND DECADE donors prevented depletion of iron stores and retained these donors in the donor pool (Gordeuk et al., 19871. Most donors are between 20 and 40 years of age (Wallace and Pegels, 1974; Bettinghaus and Milkovich, 1975; Leibrecht et al., 1976; Moss, 1976; Lightman, 19811. As individuals reach age 50, they become increasingly less likely to donate blood; individuals in their 60s make up only 2 to 3 percent of the donor population (Brewer, Rappaport, and Waterfield, 1974; Pindyck et al., 1987; Dawson, 19891. There are also racial differences between donor and nondonor groups. Surveys find higher rates of blood donation among whites than among minorities. Data from the National Health Interview Survey indicate that 32 percent of blacks interviewed said that they had donated blood at least once compared with 41 percent of whites. Only 4 percent of blacks versus 7 percent of whites reported donating in the past 12 months (Dawson, 1989). After collections from paid donors ceased in 1975 for the most part, the socioeconomic status of donors increased as individuals who donated blood to augment their income dropped out of the donor pool (Gordon et al., 1976; Surgenor and Cerveny, 19781. A recent study conducted for the Blood Center of Southeastern Wisconsin found that frequent donors had incomes that were approximately 30 percent higher than nondonors, and frequent donors reported higher educational levels than occasional donors or nondonors (Blood Center of Southeastern Wisconsin, 1986~. Recent data from the National Health Interview Survey showed that interviewees with higher levels of educational achievement were more lilcely than those with lower levels of education to report ever donating blood; individuals with more education were also more likely to report donation in the past 12 months (Dawson, i989~.~4 In a separate study of six Red Cross regions (Piliavin and Callero, in press), individuals with some college education, college graduates, and people with some postgraduate education were overrepresented in the donor samples, whereas men and women win less than a high school education and female high school graduates were unde~Tepresented. Moreover, workers in the managerial, professional, arid technical categories are more heavily represented among donors than in He general population. Overall, blue-collar and clerical workers are unde:Tepresented In the donor population. As in the past, current recruitment efforts are looking to major i40f individuals with more than 12 years of education, 50 percent reported donating blood at least once; among respondents with less than 12 years of education, 29 percent reported donating. In the group with higher levels of education, 10 percent reported donating in the past 12 months versus 2 percent in the lower educational group (Dawson, 1989).
BLOOD SUPPLY ~ 301 untapped or underrepresented sources of donors to augment the blood supply. It is likely that additional attention and research will be needed to encourage participation by individuals from these groups. However, in addition to recruiting new donors, blood collection organizations are also trying to get current donors to give blood more often. Indeed, tapping the current donor population more frequently may be less expensive, more efficient, and, in some areas, safer than recruiting new donors. Recruitment strategies for untapped or underutilized groups and repeat donors are discussed in more detail in a later section of this chapter on maintaining the safety of the blood supply. What Motivates Donors to Give Blood? Why do some people give blood and others refuse to give? Answers to this question are critical to the development of more effective strategies to recruit and retain donors. Data from donor surveys and theories of the behavioral and social sciences provide some sense of productive areas for exploration but unfortunately give no definitive answers. The AIDS epidemic raises further questions about motivation and the effect of incentives on the safety of the blood supply. The earlier threat to safety produced by the use of paid donors was eliminated by the move to art all-volunteer system. Yet there are other strategies and approaches (e.g., those that employ social pressure to motivate donation) still used in blood drives to generate sufficient numbers of donors that must now be reevaluated in the light of HIV infection. Extrinsic and Intrinsic Rewards and Incentives When asked why they donate blood, most donors report an altruistic reason for their actions (Obome, Bradley, and L`Ioyd-Griffiths, 1978; Staallekker, Stammeijer, and Dudok de Wit, 1980; Piliavin, Evans, and Callero, 19841. In some studies, donors report that giving blood provides emotional gratification, making them fee! heroic and heightening their sense of self-esteem (Szymanski et al., 1978; Burnett, 1982)e Although feeling special or altruistic may be a motivational factor, it may not be sufficient to induce actual donation. Attempts to determine the social- psychological dimensions of altruistic motivations, however, find few variables that discriminate donors from nondonors (Condie, Warner, and GilIman, 1976~. Complex acts such as blood donation are more likely to be motivated by multiple factors. Other research, for example, finds that donation is increased by incentives like the "mini" medical exam, blood typing, or cholesterol testing (where available) (Condie, Warner, and Gilman, 1976; Murray,
302 ~ AIDS: THE SECOND DECADE 1988; Rzasa and Gilcher, 19881.~s Organizations that use incentives, competitions, and raffles to recruit donors obtain significantly higher rates of donation than do organizations that do not use these techniques (Jason, Jackson, and Obradovic, 19861. However, the relative importance of venous incentives in motivating donation is not clear. One study of nondonors found that a monetary reward would not be sufficient to motivate this sample to become donors (Drake, 1978~. From his literature review, Oswalt (1977) concluded that, "only some people report donating for a reward, such as money, or time off from work; for most donors, reward does not appear to be a major motivational factor." Qualified support for the effectiveness of incentives was found by Ferrari and colleagues (1985b), who investigated the impact on donation of coupons redeemable for free or reduced-price merchandise and the possibility of winning a raffle. These incentives proved more effective than appeals to altruistic feelings but only among first-time donors. An fact, there is some evidence that rewards may actually decrease donations by regular donors. Piliavin and Callero (in press) found that feelings of moral obligation at first donation, coupled with a lack of external incentives, predicted repeat donation in a prospective longitudinal study of college donors. In an earlier study of older donors, Upton (1974) found that a combination of high levels of altruistic motivation and low levels of extrinsic reward was more effective in producing donors. Finally, although an altruistic communication before donation enhanced the likelihood of future donation for repeat donors, this effect was not seen among first-time donors In a study by Pau~hus, Shaffer, and Downing (1977~. Perceived Community Needs and Community Support Donors interviewed in several studies reported that a perceived need within the community prompted their blood donations (Grace, 1957; M. A. Cohen and Pierskalia, 1975; Leibrecht et al., 1976; Oswalt, 1977; Mell, 1979~. Indeed, an appeal to individual perceptions of community need was an approach used in New Mexico in the successful conversion from a paid to a volunteer donor system (Surgenor and Cerveny, 1978~. The message in the appeal noted that many lives could be saved by an adequate supply of blood and that each person's contribution was needed. Community norms that are congruent with donating may encourage Coffering "mini" medical examination as an incentive does not appear to satisfy all donors, however. Staallekker, Stammeijer, and Dudok de Act (1980) reported that a number of individuals who had discontinued donating complained that the mini exam was not enough of an incentive to maintain their interest in the program.
BLOOD SUPPLY I 303 individuals who are undecided about blood donation. Foss (1983) found that, at two universities known to donate substantially different amounts of blood, the one that produced more units of blood had more individuals who perceived a greater degree of community support for donation. A similar relationship between the perceived strength of support for blood donation and the success of blood drives was found by Piliavin and Libby (1986) across 17 small Wisconsin communities. Thus, the literature appears to suggest that people are most willing to respond to appeals stressing the need for blood if they perceive both the existence of the need and the existence of community support for blood donation. As the committee noted in its first report (C. F. Tumer, Miller, and Moses, 1989), communities can be defined by various criteria: shared behavioral patterns (e.g., basketball players), a common geographic area or organization (e.g., a town or a school), or a common racial, ethnic, or sexual identity (e.g., lesbian women). Thus, "community" support for donation may come from any of these levels. For example, the Irwin Memorial Blood Bank in San Francisco appealed to the lesbian community to help meet the community's blood needs while protecting the safety of the blood supply. Since the summer of 1985, the blood bank has conducted 17 successful blood drives whose main recruitment target was lesbians, a group at low risk for HIV infection. On the individual level, a personal experience with the need for blood, either through family or friends, may be associated with donation (Drake, Finkelstein, and Sopolsky, 1982; Piliavin and Callero, in press). Indeed, some blood banks have developed recruitment strategies directed toward members of families who are familiar with the use of blood and blood components. Newman and colleagues (1988) found that blood drives targeting families and friends of patients who had recently received large quantities of blood were more productive than drives that targeted first-time donors from the general population. Social Pressure Pressure to conform to the expectations of others may be a factor mo- tivating blood donation (Condie, Warner, and Giliman, 1976; Drake, Finkelstein, and Sopolsky, 19821. The belief that social pressure in- creases donations certainly underlies the recruitment strategy of blood bank "drives" at various organizations or businesses. Social pressure is also obviously applied in personal face-to-face solicitation, a recruitment technique that is reported to be highly effective (Swain and Balscovich, 16Teresa Kelly, Irwin Memorial I3100d Bank, San Francisco, personal communication, August 29, 1989.
304 ~ AIDS: THE SECOND DECADE 1977; McBa~nette et al., 1978; Jason et al., 19841. A variation on this approach is a personal telephone call to remind the prospective donor the night before a pledged donation; Ferran and colleagues (1985a) found this method to be quite effective in helping donors keep their appoint- ments. Personal contact may also help in converting nondonors to donors. Drake and his colleagues (Drake, 1978; Drake, Finkelstein, and Sopolsky, 1982) found in their studies that almost one-fifth of eligible nondonors reported that they did not give blood because no one had asked them to give.~7 These authors also contend that most eligible ex-donors do not consciously decide not to continue to donate but rather have not been recontacted. A similar important finding comes from a study by Condie (1979~. Respondents in that study who claimed never to have been asked did not consider mass media appeals to donate as "having been asked." Despite the advantages intense social pressure appears to offer in recruiting adequate numbers of donors, this strategy also has a number of drawbacks, especially in the context of AIDS. For example, to keep from revealing their risk status to friends or colleagues, some at-risk donors who cannot think of a socially acceptable excuse may give blood when pressured in a social setting. In one survey of 304 seropositive donors, almost one-third (29 percent) reported that they had been pressured to donate by colleagues at their work site, and 36 percent reported pres- sure from blood center personnel (Doll et al., 19891. Other studies of seropositive donors found that between 15 and 29 percent felt pressure to donate (Williams et al., 1987; Whitman et al., 19891.~8 Not all such donors will understand the CUE option for excluding their donation from use in transfusions. In fact, most seropositive donors do not exclude their blood through CUE, including those who subsequently admit to traditional risk behaviors. Presumably, the same problem applies to the specific donors CUE is designed to eliminate, those who are in the "window" period in which they do not yet have antibodies but are infected. Because blood testing procedures will not eliminate such units of blood from the donor pool, it is hoped that CUE will do so. Although imperfect, CUE may help decrease the risk associated with blood and blood components as donors who do elect to exclude their blood from the transfusion pool through the CUE option have been found to be much more likely to be infected 17Respondents were asked to rate the importance of six reasons for condonation. Nondonors gave their highest ratings to "nobody asked me personally." 18There are some problems in interpreting these data because no comparison groups were included. Thus, it is not known what proportion of safe donors give blood because they feel pressured to do so or what proportion of donors would have given without pressure.
BLOOD SUPPLY | 305 with HIV than donors who do not defer through CUE (Nusbacher et al., 1986; Gaynor et al., 1989b). The AIDS epidemic requires a reexamination of recruitment strate- gies that emphasize social pressure and the use of incentives. Strategies that appeal to more intrinsic motivations may hold greater promise, es- pecially when trying to solicit first-time donors and those whose blood is safe. The use of strong social pressure, on the other hand may increase the likelihood that high-nsk donors will fad] to self-exclude. The compet- ing forces of asking prospective donors to self-defer while simultaneously pressuring individuals to participate in blood drives work against each other. Both professional blood bank recruitment personnel and volunteer mobile drive coordinators should be educated regarding the implications of venous recruitment strategies. Given the autonomy of local blood collection organizations in setting recruitment policies and procedures, it may be helpful to establish and disseminate guidelines for recruitment strategies that are consistent with current needs for a safe blood supply. Factors That Inhibit Donation Oswalt (1977) claimed that medical ineligibility, fear (of needles, the sight of blood, weakness, finger or ear pecking), reactions, apathy, and inconvenience were all factors that prevented people from donating blood. More recent data (AABB, 1984) indicate that ill health, ineligibility, in- convenience, and age prevented a substantial portion of those interviewed from donating blood, but the list of factors now included the unfounded fear of contracting AIDS from the donation process.~9 Medical Ineligibility A number of studies cite medical problems as one of the reasons listed most often for condonation (L`eibrecht et al., 1976; Gibson, 1980; Boe and Ponder, 19811. Oswalt (1977) notes, however, that it is not clear whether these reports reflect actual medical conditions or beliefs, excuses, or ratio- nalizations for not donating. Disseminating comprehensible information about criteria for donor eligibility may aid in dispelling incorrect precon- ceptions and correcting invalid assumptions. In tum, such measures may 19In 1984, telephone interviews were conducted with 758 individuals from San Diego, Chicago Mi- ami, and the Baltimore-Washington area (AABB, 1984). Of the 69 individuals who had decreased or stopped giving blood, 11.6 percent believed they were too old, 21.7 percent feared exposure to AIDS, 29.0 percent reported ill health or ineligibility, 15.9 percent had no time to donate, and 1.4 percent reported that they had not been asked to donate. Of the 544 participants who did not donate regularly, 7.7 percent reported ill health, 30.5 percent feared needles, 25.7 percent believed they were ineligible, 4 percent feared AIDS, 5.5 percent found donation to be inconvenient, and 11.8 percent reported that they had never been asked to donate.
306 ~ AIDS: THE SECOND DECADE ultimately increase the donor pool (Farrales, Stevenson, and Bayer, 1977; Simon, Hunt, and Garry, 19841. Fear The association of fear (of the needle, of pain, of the sight of blood, or of weakness and dizziness) with the avoidance of donation has been well documented in the literature (Leibrecht et al., 1976; Boe, 1977; Oborne, Bradley, and Lloyd-Gr~ffiths, 1978; Wingard, 1979; Boe and Ponder, 19811. Yet, in general, only a minority of nondonors report fear as their reason for condonation, but at least In one instance fully 61 percent of "hard core" nondonors in "intense collection environments" gave fear as a reason when asked an open-ended question (Drake, Finkelstein, and Sopolsky, 1982; AABB, 1984~. Fear is reported as well by individuals who give blood. In in-depth interviews with first-time donors, 30 percent claimed that they had considered the pain involved as a drawback to donation, and 32 percent had worried about possible weakness, fainting, or nausea (Piliavin and Callero, in press). Physiological indicators of anxiety have been used to substantiate self-reported levels of fear. In several studies, both self-reported fear and high heart rates as measures of anxiety were found more often before do- nation than during the collection process (Kaloupek, White, and Wong, 1984; Kaloupek, Scott, and Khatami, 1985; Kaloupek and Stoupakis, 1985~. Anxiety by all measures is highest among first-time donors but decreases with donation experience (Kaloupek, White, and Wong, 1984; Piliavin and Callero, in press). Moreover, "regular" donors have been found to report less physical discomfort and fear than "irregular" donors (Edwards and Zeichner, 1985~. If decreased anxiety reflects the knowI- edge and experience acquired from the donation process itself, anxiety in anticipation of the unknown might be allayed by prior reassurance regarding donation and by information about the actual donation process. The groundless fear of contracting AIDS from donating blood be- came a problem with the association of disease with contaminated needles and receiving blood transfusions. In November 1985 and again in April 198S, the AABB carried out a national survey of attitudes about blood donation and transfusion (Hamilton, Frederick, and Schneiders, 19881. hn 1985, 34 percent of those polled believed that it was at least somewhat likely that they could get AIDS from donating blood. In 198S, approx- imately one in four Americans still held this erroneous belief. Among individuals who actually donate, this misconception apparently does not exist. The incorrect perception of risk associated with donating blood is
BLOOD SUPPLY I 307 thus more likely to affect new donors than repeat donors.20 Blood banks and other organizations that provide AIDS education for the general pub- lic need to continue and improve efforts to correct the misperception that donation poses a risk of becoming infected with HIV. Reactions to Donation The incidence of syncope (fainting), which reportedly occurs in only a minority of donors, has been found to be related to prior donation expe- rience, age, predonation anxiety, and several different styles of emotional coping (Kaloupek, Scott, and Khatami, 19851. Donors experiencing such untoward reactions said that they were less likely to donate again (Kaloupek, Scott, and Khatami, 1985~. Among first-time high school and college donors, between S.S and 11.7 percent experienced either mild or moderate reactions to donating blood (Piliavin and Callero, in press) whereas repeat donors were significantly less likely to report syncope, pain, or anxiety during donation. The predonation moods of reacting donors tended to be more negative than those of nonreacting donors. In addition, much greater numbers of those who had reactions reported that "I am the kind of person who should not give blood," as well as de- creased intentions to return, than were found among people who had not experienced reactions. Indeed, rates of return donation were significantly lower among those who had experienced reactions. Deferral Being deferred from donation, either temporarily or permanently, is dis- tressing for many individuals. Yet deferral is becoming more and more common as the list of behaviors associated with HIV transmission is ex- panded and tests for other blood-borne pathogens are introduced. Some individuals are free to donate when the condition that prompted tempo- rary deferral has been remedied.2i However, temporarily deferred donors are more likely than nondefe~Ted donors to perceive that they should not give blood and are therefore less likely to return. Studies have shown that temporarily deferred donors consistently show a lower rate of intending to return than do nondeferred donors, although this effect is stronger among early-career donors than among repeat donors (Evans, 1981; Piliavin, 19871. 20It is not known, however, if incorrectly perceived donation risk is associated with a history of any of the behaviors that transmit HIV infection. individuals are defeated temporarily for a variety of reasons, including fever, anemia, body weight of less than 110 pounds, or pregnancy.
308 ~ AIDS: THE SECOND DECADE As strategies to protect the blood supply result In more individuals who are permanently deferred, permanent losses to the donor pool could have more serious consequences. Because adequate supplies of blood are an important component of health care delivery, potential losses due to temporary and permanent deferral warrant further investigation. A more quantitative estimate of the impact of temporary deferral on the adequacy of the blood supply would require additional information, including measurement of actual return rates as opposed to presently available measures of the intention to return. Permanent deferral raises additional data needs, including quantitative measures of loss to the donor pool and the blood supply as a result of exclusionary procedures. Inconvenience The lack of a convenient donation opportunity is seen as a major reason for not donating blood (Caruso, 1978; Drake, 1978; Talafuse, 1978; Staallekker, Stammeijer, and Dudok de Wit, 1980; American Red Cross Blood Services, Los Angeles-Orange Counties Region, 1981; Drake, Finkelstein, and Sopolsky, 1982~. Donors and nondonors alike have cited the length of time it takes to donate blood as a constraint to donation (Oswalt and Zack, 1976; Pau~hus, Shaffer, and Downing, 1977; Mell, 1979; Callero and Piliavin, 1983; Piliavin and Callero, in press). Unfortunately, there are no studies that examine the association between actual time spent at the donation site and the perception of time spent. However, inconveniences other than time also appear to affect donation. Perceived delays, inconvenient blood collection hours, and locations that are not readily accessible are factors that inhibit repeat donations (American Red Cross Blood Services, Los Angeles-Orange Counties Region, 19811. Blood collection organizations have addressed the issue of convenience in part by collecting blood at mobile sites. The limited space available in these small facilities, such as bloodmobile vans, however, creates special problems related to privacy, especially when donors are questioned regarding behaviors that may be sensitive or illegal. If the screening process becomes more involved as efforts increase to eliminate donors who are at risk of AIDS, it may take longer to complete intake interviews, further increasing the level of inconvenience. As yet, optimal conditions for collecting all relevant data to screen donors while minimizing inconvenience have not been established. The use of separate "tracks" for first-time donors and repeat donors may alleviate some problems of convenience for regular donors. A separate and faster track for those who are familiar with the information, interview, and donation process may be more convenient for repeat donors and for staff who should spend more time with first-time donors. However, the design
BLOOD SUPPLY ~ 309 of faster track processing would need to ensure that significant changes in risk-associated behavior or other eligibility cr~tena would not be missed in repeat donors assigned to fast-track processing. The ideal donor experience is one involving personal attention, pro- fessional treatment, and a clear exchange of information in a sewing that expresses concern for the donor and his or her privacy. The quality of the donation experience, from registration through the health history, venipuncture, and donation, is critical in leading individuals to commit themselves to continued giving. The need of blood collection organi- zations to proceed in an efficient manner for economic reasons must be weighed against the need to inform donors adequately about HIV infection and the importance of deferral for those who may be at risk. Behavioral Theory and Its Application to Donor Recruitment Research on blood donation has been largely empirical; theoretical work in this area has been more limited. Applying relevant theories of the social and behavioral sciences to the problem of donor recruitment may help in developing new strategies appropriate to the concerns of the post-AIDS era. This section discusses several such theories and their applicability to donor recruitment strategies including the operation of personal norms and a factor called the attribution of responsibility to the self, the use of role models, the theory of reasoned action, arid attribution theory. Internal Versus External Antecedents to Action Any action including blood donation is preceded by a series of events both internal and external to the individual. Such events include internal states, such as a belief or attitude, or external forces, such as peer pressure or community norms.22 Psychologists and sociologists have a long-standing interest in these antecedents of behavior and have proposed a variety of theories to predict the conditions under which specific behaviors will occur. Attribution theory (Heider, 1958; Kelley, 1967) looks at how people make causal judgments about their behavior, how they decide whether to "attribute" an action of theirs to internal or external sources. Indeed, psychologists have found that people often make inferences about their 22 Norms are shared expectations that guide behaviors, such as table manners or sexual behaviors; they may be seen as the "shoulds and oughts" for individual behavior. They are the standards to which a society or group expects itS members to adhere.
310 ~ AIDS: THE SECOND DECADE attitudes and the kind of person they are by reviewing their external behavior rather than their internal cognitions or affect. But internal factors play other important roles in motivating behavior. People prefer to see themselves as inner directed and helpful. According to attribution theory, people who appear to be directed by internal forces are seen as more powerful and are accorded more status; a strong person who performs an altruistic or helpful act without coercion of any kind is seen as a better person than another individual who performs the same act but is perceived as weaker and externally controlled. Other things being equal, people who perceive that they have taken action without external coercion or reward are likely to attribute to themselves a predisposition toward that action. In turn, once such an attribution has been madeonce they decide that "I am the kind of person who does such things" they are more likely to act in ways consistent with that attribution in the future. Several studies have shown that people see themselves as acting less altruistically if they provide help after being offered money as an incentive, if they act under reciprocity pressures (that is, if the person they helped had previously helped them), or if expectations to help have been made obvious (Batson et al., 1978; Thomas and Batson, 1981; Thomas, Batson, and Coke, 19811. A review of research on donor motivation by Batson and colleagues concludes: "These studies suggest that, over time, the use of extrinsic pressure to elicit help from morally mature adults can backfire" (Batson et al., 1987:595~. Two strategies based on attribution theory have been applied to efforts to improve donor recruitment: the "foot-in-the-door" and the "door-in-the-face" approaches. The foot-in-the-door technique involves an initial small request (e.g., to put up a recruitment poster), followed by a larger critical request (e.g., to give blood). Theoretically, after individuals comply with the initial request, they define themselves as "helping peo- ple" and will continue to comply in order to maintain that self-perception. The door-in-the-face technique involves an initial request that is so large (e.g., commitment to a long-term donor program) that the individual will surely refuse. This initial contact is then followed by a lesser, more man- ageable request (e.g., one blood donation). Theoretically, refusing the first request makes one uncertain of one's helpfulness whereas agreeing to the lesser restores one's initial self-appraisal. Studies that have applied these concepts to blood donation have had varying results. Cialdini and Ascani (1976), in face-to-face interviews with prospective donors, found that the door-in-the-face technique ob- tained greater verbal compliance than either the foot-in-the-door approach or to a single request. It did not, however, result in more donations. The
BLOOD SUPPLY ~ 311 foot-in-the-door procedure was generally found to be ineffective in this study. Later research (Foss and Dempsey, 1979) varied the delay between the small and large requests of the foot-in-the-door method, as well as the strength of the initial small requests. In all cases, the effect of the foot-in-the-door approach was insignificant. In a more recent study, Hayes and coworkers (1984) contacted active donors, inactive donors, and nondonors by telephone. Their initial small request was to place the individual's name on a "list of potential donors to be called and asked to donate blood in the event of a shortage." Agreement to this request varied by donor group: 85 percent of active donors agreed to be included on the list and 33 percent of those on the list actually donated; 71 percent of inactive former donors signed up and 33 percent donated; but only 40 percent of nondonors complied with the initial request and only 11 percent gave blood. However, for all groups in this study, the foot-in-the-door approach was more effective than a single request for an actual donation and was significantly more effective in producing actual donations than the door-in-the-face approach.23 Thus, studies that have applied attribution theory to donor recruit- ment strategies have produced inconsistent results. Overall, they provide some evidence that the foot-in-the door approach has merit, especially when the initial request is a meaningful one. It is probably not the self-attribution "I am a helpful person" that is critical here but the more specific, internalized self-definition of "I am a blood donor" (Callero, 1983; Piliavin and Callero, in press). Other theories are also concerned with the internal versus external stimuli for action, including the role of social norms in motivating behav- ior. People learn about their community's norms or standards for behavior in a variety of ways; for example, children are socialized to community standards at home, in school, and by their peers. After this socialization process is complete, however, some of the community norms become internalized; that is, they are incorporated into the individual's personal set of attitudes and beliefs and become internal standards of behavior. Again, studies of blood donors have found that internal factors are more potent motivators than external forces; that is, internal, personal noes are more powerful predictors of blood donation than external community norms (Piliavin and Libby, 1986~. 230f the 286 participants who were asked if they would put their name on a donor's list (the so-called foot-in-the-door approach), 189 (66 percent) signed up for future donation and 55 (or 29 percent of the list) actually gave blood. The door-in-the-face approach was attempted with 316 subjects, 299 (or 95 percent) of whom agreed to sign up for a long-term donor program. However, only 10 individuals who signed up actually gave blood.
312 ~ AIDS: THE SECOND DECADE Schwartz (1970) found that individuals who joined a bone marrow donor pool scored significantly higher than nondonors on scales that assessed the degree to which people ascribed their actions to an internal factor called attribution of responsibility to the self. This personality characteristic is thought to predict the willingness of individuals to engage in a variety of altruistic acts. Blood donors were more likely to score higher rather than lower on scales for attribution of responsibility to the self (Zuckerman, Siegelbaum, and Williams, 19771.24 This internal sense of responsibility to others may be linked to the economic concept of free ndership. Free ridership is the tendency of some people to let others pay the costs of public goods and services that are available to all (e.g., public radio and television). Because the blood supply is a public resource, it may be useful to consider the implications of the concept of free ridership when trying to understand why some individuals choose not to donate blood. In one study that attempted to discern differences between donor and nondonor populations, nondonors were found to be more likely to display characteristics consistent with free ridership (Condie, Warner, and Giliman, 19761. Thus, donation may be associated with a belief that one should contribute to public resources that one might reasonably expect to use in the future. Intention and Action The theory of reasoned action provides insight into how individuals make decisions to take action (Fishbein and Ajzen, 19751. In general, it is assumed that information will change beliefs and attitudes, which will ultimately result in a specific behavior. The theory of reasoned action finds that the intention to act is the immediate determinant of behavior but that four factors precede the establishment of an intention: (1) the person's attitude toward the behavior (e.g., that donating blood is good), (2) the person's beliefs about the behavior (e.g., that donation is the responsibility of every eligible individual), (3) the person's perception of what others will think of the behavior (e.g., donors are seen as helpful and inner directed), and (4) the value the person places on the approval of others. This theory would predict that a person who values the approval of peers, who believes that they support donating blood and that blood donation is a good thing to do, is more likely to give blood than a person who does not share these beliefs. Empirical work in blood donation confirms the theoretical postulate 24A study of blood donors found that 34 percent of individuals with high attribution scores gave blood when solicited, as compared with 10 percent of individuals with low scores (Zuckennan, Siegelbaum, and Williams, 1977).
BLOOD SUPPLY ~ 313 that intention is the antecedent to action (Schwartz and Tessler, 1972; Pomazal and Jaccard, 19761. However, the relationship between the perception that others expect one to donate blood and either an intention to donate or actual donation is far from clear (Bagozzi, l981a,b, 1986~. Methodological complications posed by very heterogeneous samples may cloud such a relationship if it in fact exists. Indeed, Charng, Piliavin and Callero (1988) found that the perception that others expected donation to occur had some effect on the donation behavior of early-career donors; it had less effect on the behavior of more experienced repeat donors.25 One way to reinforce an intention and impel the resulting donation of blood is to persuade a perspective donor to schedule an appointment, a practice that makes it more likely that blood will actually be given. A study of intentions conducted by Walz and Coe (1984) compared the influence on donation rates of three different strategies: (1) prospective donors were informed that a bloodmobile would be in their area; (2) prospective donors were informed about the bloodmobile and were sent a checklist of dates to which they could commit themselves; and (3) prospective donors were not given any information other than mass media messages about the blood drive. Individuals who were sent the checklist of dates and asked to commit to a scheduled appointment were more likely to give blood than individuals in either of the other two groups. Similarly, studies using planned variations of phone call reminders to prospective donors have found that strategies leading to a specific commitment to donate produce more donors than mere reminders of a blood drive (Lipsitz et al., in press). One blood center applied these findings over a three-year period during which all donors were asked to schedule a specific appointment to donate. The researchers claimed that the "show" rate of donors more than tripled over that period (Walz and Coe, 19841. Following temporary deferral, reports indicate that future donations are most likely if specific appointments are made. In one study (Walz, McMullen, and Simpson, 1985), potential donors were contacted two days after they were deferred and asked if they would be willing to try to give again. Those who were willing were scheduled or called again near the time when they would be eligible. For those deferred for upper respiratory infections, the return rate was 67.5 percent, and the deferral rate at the second intake was only 2.6 percent. For donors with a low 25The evidence provided by Charng and colleagues is correlational (i.e., it demonstrates a relationship between two variables but does not elaborate on the nature of the relationship). Thus, one cannot rule out the possibility that behavior influences perception.
314 ~ AIDS: THE SECOND DECADE hematocrit, the return rate was 59.6 percent, and the deferral rate at the second intake was only 8.2 percent. Strategies to establish intentions to donate may also be helpful in developing, repeat donors. A recent study of 180 first-time donors who had responded to an emergency appeal compared the effectiveness of two follow-up strategies intended to encourage repeat donation. All donors received a personalized thank-you letter. Half also received a postcard reminder about scheduling another donation, followed by a telephone call to set up an appointment. In the test group, 33 percent returned within 4.5 months; in the control group (no postcard or telephone call), only 11 percent of donors returned (Freiburger and George, 19881. Role Models Many learned behaviors reflect the observed and interpreted actions of others. In attempting to learn by example, people may look to and mimic individuals they perceive to be powerful or successful or individuals who provide a believable example of a desired demeanor that is possible to imitate. Such individuals serve as role models and can effectively influence the behavior of others. The family provides role models that are critical in the primary socialization of chidden. The family can influence behavior in three important ways to encourage donation: it can develop values that are consistent with helping others and positive involvement in the commu- nity; it can provide information; and it can offer role models. Family role models may be the most powerful of all of these influences on children's behavior. One would expect that children who observed their parents do- nating blood would themselves be likely to do the same in the future, and some data support such an expectation. Almost 60 percent of a sample of 237 first-time college donors said that someone in their families gave blood; of that 60 percent, nearly half stated that their family members gave regularly (Piliavin and Callero, in press).26 These figures are striking when one considers that only between 6 and ~ percent of people who would be eligible in the general population give blood each year. As part of a more general strategy to use regular donors as recruiters, blood drives have looked to family members with a history of blood donation to serve as role models, introducing children and teenagers to the blood donation process and recruiting those who are eligible to donate. Bringing children to the donation center may help to demystify blood donation and link it to everyday life. Educational programs provided 26However, there was no comparison of donors reporting a family history of donation to donors whose family members do not give blood.
BLOOD SUPPLY ~ 315 through school-based courses in health and human sexuality can reinforce messages provided by the family and supply additional information on the function of blood, the use of blood and blood components, and even the connection between lifestyle and deferral criteria. Parents who are regular donors might use their teenager's seventeenth birthday to introduce him or her to blood donation. Role models for donation need not rely exclusively on the family. The experimental design of one study (Rushton and Campbell, 1977) paired an older woman confederated with female students ostensibly to go together to an office where the student was to receive payment for participating in the study. On the way, they were recruited for a blood donation. In some of the cases the confederate was asked first and agreed to give blood, serving as a positive role model; in other cases the student was approached first. When students were asked first, only 25 percent agreed to donate, but none actually appeared for the appointment, even after receiving four reminder cards. Of the students exposed to the role model provided by the confederate, 67 percent agreed, and 33 percent actually donated. The notion of using committed, regular donors as role models and to recruit new donors is a recently implemented strategy that perhaps deserves more attention in future efforts. For example, the "Adopt A Donor" program (Cox, 1987) relies on committed donors to motivate donors who have given once but have not returned. This activity uses repeat donors as role models for other donors and capitalizes on their willingness to extend their volunteer contribution. Linking Organizational and Theoretical Issues in Donor Recruitment Strategies Several years ago, Piliavin, Evans' and Callero (1984) proposed a four- step mode! to enhance donor commitment: (~) identify and neutralize the negative aspects of donation, (2) develop internalized motives for dona- tion and integrate them into the self-concept, (3) develop a behavioral intention to continue giving blood, arid (4) develop an actual habit of donation. Piliavin and coworkers suggested that donors move through stages that roughly parallel these processes. Negative perceptions associ- ated with donation tend to decay over time and with repeat donations, as shown in a study in which individuals who became regular donors were interviewed at two different times: at their first donation and approxi- mately 18 months later (Piliavin, Evans, and Callero, 19843. On both 27 In psychological experiments, a confederate is a member of the experimental team who interacts with subjects in a prescribed fashion but does not reveal his or her role to the subject.
316 ~ AIDS: THE SECOND DECADE occasions, donors were asked to identify the negative aspects they had considered over the course of their donor history. At their first donation, 30 percent said they remembered thinking about pain; 12 percent thought of inconvenience; 32 percent considered the possibility of weakness, fainting, or nausea; and 11 percent thought of possible deferral, mistakes by the staff, or fear of the unknown. In the later interview, most of the donors could not remember considering any drawbacks at their most recent donation. A study that explored factors related to decisior~s to donate a sec- ond, third, and fourth time found interesting differences (Callero and Piliavin, 19831. All participants were asked to evaluate retrospectively them motivations for donating blood, and the pain, anxiety, and incon- venience associated with the experience. Individuals who reported an external stimulus for the first donation (e.g., participating because of a blood drive) were nevertheless likely to make a second donation; whether they made a third donation, however, depended on internal factors (e.g., a belief that donation is important or a positive self-definition as a blood donor). Pain and anxiety associated with the first donation experience had a negative correlation with the return for a second donation but were not related to later donations. Finally, recall of a short waiting time was related to the decision to donate a second and third time but was more strongly associated with the third donation. These findings are consis- tent with the mode] suggested above: first, the donor must deal with the negative aspects of donation such as pain and anxiety; later, internal motivations begin to contribute to an increasing commitment to blood donation. Change in attitudes and perceptions quite often result from the do- nation experience. Studies that follow donors prospectively have found that later donation experiences are less stressful than first donations. It appears that motivations for donation also change over the course of a donor's "career." Lightman (1981) found that external motivations (e.g., the company of a friend, persuasion or encouragement by others, the existence of a blood drive or emergency) became less important over time. However, internal motives (e.g., a general desire to help others, a sense of duty, support for the work of the Red Cross) were rated as more important motivators win subsequent donations.28 The author concluded that, "twlith the repeated performance of a voluntary act over time, the sense of personal, moral obligation assumed increasing importance as a 28It is not possible to infer a causal relationship, however. Indeed it is not possible to rule out altema- tive explanations, e.g., that upon subsequent donation' more repeat donors reported such motivations or that donors "susceptible" to such motivations go on to become repeat donors.
BLOOD SUPPLY ~ 317 motivator; a supportive and favorable context in general became muc less vital" (Lightman, 1981:64~. A recent prospective longitudinal study of college students supports this conclusion (Piliavin and Callero, in press). Theories such as those discussed above can serve as the basis for developing new strategies of donor recruitment and can augment existing social marketing approaches that have been used to divide the potentia donor population into homogeneous segments and to target recruitment efforts to specific segments (Kotler and Roberto, 19891. In addition, new target groups, as defined by venous demographic characteristics (discussed below), may present further opportunities for specialized re- cruiting efforts to safely augment the donor population and the blood supply. PROTECTING THE BLOOD SUPPLY FROM HIV INFECTION Protecting the blood supply from HIV infection rests on recruiting indi- viduals who do not engage in behaviors that transmit the virus, excluding those who are at even minimal risk, and testing donations to detect anti- body to HTV. Because of the close interconnection between the safety of the blood supply and its adequacy, however, recruitment, exclusionary, and testing procedures must be implemented with great care. Attempts to ensure the adequacy of the blood supply by using social pressure to increase donations or by seeking donations from social and ethnic groups currently underrepresented in the donor population may raise concerns about safety if high-risk behavior is not adequately considered. Efforts to enhance the safety of the supply by excluding individuals who report high-risk behaviors or by providing HIV antibody testing at blood centers raise other issues. Such efforts must deal with complex issues related to the perception of risk, the types of mechanisms used to encourage self-deferral, and the inappropriate use of blood centers for HIV antibody testing. The changing nature of the epidemic its extension to broader age groups and to women further complicates efforts to balance the demands of safety and supply. The delicate balance between safety and adequacy of supply is il- lustrated by the response of recruitment strategies to a problem posed by donor demographics. Minority group members are underrepresented among donors, resulting in an excess of certain blood types (e.g., Group A, which is more common among white donors) and a shortage of others (e.g., Group B. which is more common among blacks). Yet intensified recruitment strategies that attempt to redress the problem by focusing on minorities would have to take into account the fact that minorities in some
318 ~ AIDS: THE SECOND DECADE areas are more heavily affected by the AIDS epidemic than are whites. Recruiting "safe" donors thus becomes a challenge that parallels that of obtaining sufficient supplies of blood across all blood groups. With these considerations in mind, in the following section the committee looks at donor recruitment issues as they pertain to the safety of the blood supply. Recruiting "Safe" Donors Designing effective strategies to recruit healthy donors requires an un- derstanding of the differences between donors found to be infected with a blood-borne disease (in particular, HIV) and those whose blood is "safe." Surveys of HIV infection among blood donors find more in- fection among men than among women, more infection among younger donors than among older ones, and more infection among minorities than among whites. Overall, this pattern is consistent with the trends seen in serologic surveys of the general population. However, individuals with no identifiable risk factors comprise a significant portion of blood donors who are found to be infected (Cleary et al., 1988; Ward et al., l98Sa; Petersen et al., 19891.29 In contrast to the pattern in reported AIDS cases, very few HIV-infected blood donors are intravenous drug users. In at least one study, a new trend is reported: the proportion of HIV-infected blood donors exposed through heterosexual contact has increased over time as the proportion of cases ascribed to homosexual contact has declined (Leitman et al., 19891. The same kind of shift has also been reported in New York City, where between 1985/1986 and 1988 there has been a clear shift in risk factors among HIV-infected blood donors away from homosexual contact and toward heterosexual contact, especially sexual contact with intravenous drug users (Gaynor et al., 1989a). Unfounded assumptions and changing risk patterns thus complicate the effort to devise donor recruitment strategies that will ensure both a safe and adequate blood supply. The practice of directed donation, for example, raises safety as well as supply issues even though recipients and their families perceive this form of donation as safer than donation by unknown volunteers from the general population. Directed donation has been questioned by some blood bankers who believe that implementing it on a wide scale could undermine or disrupt the nation's blood supply. Existing data are insufficient to test this belief, which assumes that many 29The fact that intravenous drug users are undeITepresented in surveys does not indicate that they are entirely absent from the donor population. Surveys of intravenous drug users have found that approximately 25 percent have donated or sold blood in the past ten years; the majority reported selling their blood to commercial plasma collection organizations (Chitwood et al., 1989; Nelson et al., 1989).
BLOOD SUPPLY 1 319 regular donors would cease to donate except to meet the specific needs of family and friends. Available data do suggest, however, that directed donation poses safety problems. Directed donors are more likely than the larger donor population to be first-time donors, and first-time donations are more likely to be positive for markers to infectious diseases, such as hepatitis A and B and HIV (Starkey et al., 19891.3° Many blood banders, moreover, believe that blood from family and friends who give under pressure may not be as safe as that from volunteers. In fact, the available evidence suggests that there may be no significant difference in the rates of HIV or other viral infections in blood from directed donation and in units from the general donor pool (Fischer et al., 1986; Starkey et al., 19891.31 Given the need to enhance donations in genera] and to increase donations from underrepresented groups (e.g., minorities) in particular, it is critical for blood centers to fine-tune their recruitment strategies and to identify the most promising variations of these strategies. The adequacy of the blood supply in the past has depended on age and gender groups (e.g., 20 to 40 year old men) that parallel those at increased risk for HIV infection. At the same time, relatively safe groups, such as the elderly, have been underrepresented among donors. Yet among all these groups are certainly individuals who could provide safe blood. Some of the strategies that could be used to discriminate between high- and low-nsk prospective donors within subpopulations are discussed below. Racial and Ethnic Minority Groups Even though minorities are overrepresented in every AIDS risk group32 30Starkey and colleagues (1989) found that first-time directed donations (N = 5,946) were 2 8 times more likely to be positive for hepatitis B surface antigen than donations from the total volunteer group (N = 444,637). 31It should be noted, however, that there are methodological problems that make interpretation of comparisons between volunteer and directed donations complex. In their review of studies of directed and volunteer donors, Strauss and Sacher (1988) found that (1) the comparison groups were often very different in size; (2) it was unclear whether comparison groups were tested concurrently; (3) the methods and results of statistical analyses were often missing; (4) the male-to-female ratio of donors was often absent from reports of studies; (5) the proportion of first-time and repeat donors was not always known; and (6) no study followed transfusion recipients prospectively to note the incidence of transfusion-associated infections. 32Rates of hepatitis B. another infectious disease that may be sexually transmitted and is incompatible with blood donation, also exhibit racial differences in population-based samples of the noninstitution- alized civilian population. Data from the second National Health and Nutrition Examination Survey (NOBLES It), which collected blood from 14,488 participants between 1976 and 1980, found evi- dence of hepatitis B infection in 13.7 percent of blacks and 3.2 percent of whites (Centers for Disease Control, 1989). For all age groups, rates of infection were significantly lower for whites than blacks.
320 ~ AIDS: THE SECOND DECADE and minorities generally bear a disproportionate burden of illness, HIV in- fection is not arbitrarily or evenly distributed within minority subgroups. Moreover, it is participation in high-risk behaviors and not membership in any particular group that confers a risk of AIDS. Therefore, strategies to recruit blood donors that are directed toward minorities should seek those whose behavior predicts a low risk of HIV infection. Efforts to recruit such low-risk donors may wish to target specific organizations and institutions (i.e., work sites and schools) in communities with large and stable minority populations. Presumably, the general principles of using local social networks, role models, and convenient donation settings to recruit and retain donors would apply to these special groups as well. Wingard (1979), for example, had considerable success in recruiting blacks for blood donation at work places that employed large numbers of black workers and involved black volunteers in recruitment efforts. Another blood center staged a highly successful blood drive by working with a black fraternity and the Black Caucus on a major Eastern university campus (C. Schroeder, 19871. The center invited a nationally known speaker, who stressed to the black student leaders that one-third of the individuals who require transfusion of rare blood types are black. He also discussed the special needs of patients with sickle-cell anemia, a disease almost exclusively found among blacks. The student leaders then disseminated the information to their groups. The goal set by the organizers of the blood drive was 50 units; the yield was 70, including 18 first-time participants. Donors stated that after this "tailored" experience, they would be much more likely to donate at one of the main campus drives. A different approach to enhance minority recruitment and to tap segments of the black population presumed to be at lower risk was used for a blood Hive scheduled during Black History Month in Norma (Eckert and Neal, 19841. The local blood center offered sickle-cell screening to the community and publicized the opportunity to donate blood in connection with the screening. Black community leaders were involved during the planning stage, and various media strategies were employed to inform people of the event. More than 500 first-time black donors gave blood during the month (a 20 percent increase), and more than 600 individuals were screened for sickle cell, including one male who was found to have the disease. Although these strategies have proven successful, additional work is needed to find the best strategies for targeting those segments of the diverse minority populations at lowest risk for HIV infection.
BLOOD SUPPLY ~ 321 Age Groups A somewhat different set of issues applies to strategies for targeting particular age segments of the population of potential blood donors. Because the prevalence of AIDS and HIV is low among the elderly and late middle-aged, these subpopulations are an obvious focus for blood drives. The likelihood of high-risk behavior is also presumed to be low, so that these groups represent relatively "safe" candidates for blood donors. Nonetheless, the elderly and the late middle-aged segments of the population are also underrepresented in the blood donor pool. Arguments against recruiting those over age 65 have centered on the possibility that they will be taking medication that is inconsistent with donor eligibility guidelines and on the notion that they would be more prone than younger people to adverse reactions associated with donation. These considerations may have made sense decades ago, but in view of the health and vigor displayed by many older people today, they are being reevaluated by many blood collection centers. As a result, recruitment of older people in those states in which it is legally permissible has increased in recent years. Indeed, targeted recruitment programs are already in effect in some areas of the country that have concentrated populations of older individuals. Schmidt (1984) reported on a program in southwest Florida that has actively recruited senior citizens since 1978. In 1981, 2.5 percent of the center's donors were over the age of 65, and by 1984 the figure had increased to 5 percent. Furthermore, this study did not support the notion of increased incidence of adverse reactions among older donors. On the contrary, "senior donors" were less likely than other donors (0.04 percent versus 2 percent) to experience untoward reactions. A study conducted in New York (Pindyck et al., 1987) supports Schmidt's conclusion that older individuals can be a significant resource for blood collection. In a comparison of approximately 600 donors between the ages of 66 and 78 with a group 52 to 65 years old, no differences were found in reaction rates following donation, and there was only a small difference (~8 versus 9 percent) in onsite deferral rates. As the authors point out, blood donation may also have a positive psychosocial impact on older donors. The psychological rewards that accrue to all regular donors may be particularly valuable to senior donors, whose opportunities to contribute to the community in other ways may be somewhat restricted. Thus, recruitment efforts may wish to reconsider the current strate- gies that may overlook both older and younger age groups (e.g., drives conducted at work sites). However, successfully reaching more diverse
322 ~ AIDS: THE SECOND DECADE age groups may require additional information on motivational and eli- gibility factors. Genders Of all the demographic factors related to donation, the issues posed by gender may be the most important. Women, especially women who are repeat donors, have in the past been considered to be relatively safe in terms of the risk of HTV infection (summing et al., 1989~. Indeed, Cumming and colleagues recommend that "every effort should be made to recruit and retain female donors" (1989:9451. Now, however, the changing risk profile of women as the epidemic enters its second decade (see Chapters ~ and 2) raises new concerns about efforts to step up recruitment of women as donors. Moreover, many women are unaware of being at risk because their exposure to the virus is indirect (i.e., their risk is related to the behaviors of their sexual partners which may be clandestine and may include bisexuality or occasional drug injection), thus posing significant and increasing problems for self-deferral mechanisms. In one large study, for example, the proportion of infected women who were unable to identify a risk factor for HIV infection was equal to that reporting heterosexual contact with an at-r~sk man (Ward et al., l988a).33 For such women, who do not perceive that they are at nsk, voluntary self-deferral is not possible (Cleary et al., 1988~. Even if the safety concerns related to the changing risk status of women and the adequacy of self-deferral mechanisms could be resolved, the problem of recruiting women for regular, repeated donations remains. Currently, more than 50 percent of first-time donors are female, but women constitute less than 30 percent of the committed long-term cadre of donors. Considering the potential importance of women to the donor pool, research on the causes of the attrition could be crucial to blood donor recruitment. A variety of informational and structural barriers may inhibit women from donating blood, including the need for child care at the donation site and education regarding when to return to donate after pregnancy and nursing. Additional research to pinpoint such barriers to regular donation and identify their solutions should be part of any overall strategy to correct the underrepresentation of women. One reason women withdraw from the pool of donors is deferral for low hemoglobin levels. As suggested earlier, this problem can be addressed for many women by 330f the 818,629 participants, less than half (42 percent) were females; 54 women were found to be seropositive. Of Me 34 infected women who were interviewed, 15 reported heterosexual contact as their risk factor, and 15 cited no identifiable risk (Ward et al., 1 988a.)
BLOOD SUPPLY I 323 providing iron supplements. Exactly what proportions of female donors are lost as a result of other factors is not currently known. In addition to the above focus on recruiting underrepresented groups, issues related to not recruiting or defernng individuals who are at higher risk for HIV infection remain a problem. This problem relates especially to men, because most at-risk individuals in the United States are men. Men who have sex with other men but do not consider themselves to be homosexual present a particularly difficult problem. Men who self- identify as homosexual are more likely to self-defer than men who are bisexual. Delivering comprehensible messages to male donors who report sexual contact with both men and women is thus a high priority task. The following section deals with issues related to excluding at-risk donors. Exclusionary Procedures: The Donor Perspective It is clear that HIV antibody testing detects the majority of but not all individuals who are infected with the virus. Self-deferral mechanisms are intended to eliminate infected donors who are not identified through antibody testing. Self-deferral has apparently achieved some of its de- sired end of protecting the blood supply. Even in the early years of the epidemic, many at-nsk individuals were aware of the need to self- exclude and acted accordingly (Pindyck et al., 19851. In March 1983, blood collection organizations introduced the request for self-deferral of homosexual or bisexual men with multiple partners, a practice that re- sulted in halving the rate of blood donation by an at-risk group of I87 donors who were studied retrospectively (Wykoff and Halsey, 19861. Perkins, Samson, and Busch (1988) also found sizable decreases (from 100 in 1982 to 45 in 1983) in the number of blood donations provided by individuals later diagnosed as having AIDS after introduction of an information sheet requesting male donors with multiple male sex partners to defer themselves from donating. In September 1985, the Red Cross introduced new, more restrictive wording ("If you are a male who has had sex with another male at any time since 1977, you must not give blood or plasma") in the informational materials given to all donors. Following the introduction of this statement, a statistically significant reduction in the percentage of confirmed HIV antibody-positive donors was observed in selected regions of the counhy.34 Reductions in seropositive donations 34In one study from the American Red Cross Blood Services, Connecticut Region, the rate of Western blot-positive donors dropped from 0.034 percent identified in the nine weeks preceding the addition of this wording to 0.0084 percent in the following nine weeks (KaIish, Cable, and Roberts, 1986). In a second study (Perkins et al., 1987), decreases were also reported in the proportion of HIV-positive donors over time (from 0.0272 percent in the period June 28, 1984' to September 4, 1984, to 0.0033
324 ~ AIDS: THE SECOND DECADE were also observed following the introduction of a self-exclusion call- back system described earlier (Perkins, Samson, and Busch, 19881. In addition to the effects of self-deferral of high-risk individuals (Pindyck et al., 1985; Kalish, Cable, and Roberts, 1986; Wykoff and Halsey, 1986; Hughes et al., 1989; Leitman et al., 1989), some of the change is the product of elimination of donations from individuals who had already been tested by a blood collection organization and the request that donors found to be positive not return to donate again (Ward et al., l98Sa; Cumming et al., 1989~. Despite indications of success, however, concerns remain regarding the effectiveness of self-exclusionary procedures. There are important questions related to the perception of risk and nondeferral among high- nsk donors that remain to be answered. A significant number of donors infected with HIV did not self-exclude because they did not believe they were at nsk. These donors cite the following reasons for this belief: they had changed their behavior, they had not engaged in risky behaviors recently, they did not feel sick or have HIV-related symptoms, Hey had only limited numbers of sexual partners (one to three), they had been in a monogamous relationship, they lived a healthy lifestyle, or they did not find their behavior congruent win their personal interpretation of "promiscuous" activity (Williams et al., 1987; Doll et al., 1989; Leitman et al., 19891. Donors who cannot identify a risk factor, of course, do not perceive a risk (Williams et al., 1987; Doll et al., 1989; Gaynor et al., 1989b; Leitman et al., 19891. Wil~iams35 interviewed 158 HIV antibody-positive donors from three American Red Cross blood service regions in 1985 and 1986; 17 percent of male donors and 56.5 percent of female donors had no identifiable risk factor. Fewer than half (44 percent) indicated that they knew or suspected that they were in a high- nsk category for AIDS at the time of their donation. In a survey of more than 800,000 donors from three urban areas in the United States (Ward et al., 1988a), more than half of infected men who reported same-gender sexual contact also reported intercourse with women. An anonymous questionnaire administered to 867 homosexual and bisexual men in Boston between October and November 1984 found that 7 percent reported donating blood in the year immediately preceding the survey (Seage et al., 19881. The men who had donated most recently were younger, less likely to know someone with AIDS, and less likely percent for the second half of 1986). These figures include a drop from 0.0108 to 0.0065 percent after the introduction (in 1985) of the wording. 35Alan E. Williams, American Red Cross, Jerome H. Collared Laboratory, personal communication, April 30, 1990.
BLOOD SUPPLY ~ 325 to have received information about not donating from gay-oriented pub- lications than the men who had not donated recently. The most recent donors were also less likely to be open about their risk status and less likely to perceive themselves to be at risk for HIV infection. This lack of perception of risk among male donors found to be infected (as well as among females who may not know about risk behaviors of their sexual partners) has been reported in several studies and has obvious implica- tions for self-exclusion strategies (Williams et al., 1987; Doll et al., 1989; Leitman et al., 19~9~.36 The changing face of the epidemic makes it essential that donor screening techniques continue to be monitored for effectiveness. One recently adopted change in the health history interview is to focus on risk behavior rather than on populations at risk. This change reflects the realization that many people who engage in risky behavior do not identify themselves as members of a population at nsk. For example, some men who engage in same-gender sex nevertheless do not identify themselves as homosexual (Doll et al., 19893. The extension of the epidemic to individuals who have been considered "safe" donors (e.g., women) further emphasizes the need to screen potential donors by risk behavior rather than risk groups. Both donors and blood collection personnel complain about the complexity of the AIDS risk information materials provided to donors. Misunderstanding information or instructions used in self-deferral was apparent in a small study that considered how well donors understood the informational matenals. When 31 seropositive donors were inter- viewed regarding their understanding of the "What You Should Know About Giving Blood" pamphlet used by the Red Cross (Chambers et al., 1986), 90 percent said they had read the pamphlet. However, more than half of those who were members of a high-nsk group indicated that they did not understand the self-deferral requirement, which is based on HIV-associated risk behaviors. Other studies confirm donors' diffi- culties in comprehending predonation information brochures. A survey of 304 seropositive donors found evidence of misperceptions and mis- understandin~g of deferral information in a small but worrisome subset: 16 percent did not understand that their blood would be tested for HIV antibody, and only 5 percent elected to exclude their blood through the CUE option (Doll et al., 19891. These findings point to particular prob- lems for individuals with low educational levels (Clea~ et al., 19881. 36A study of 113 seropositive blood donors in New York found that those who perceived themselves to be at risk were more likely to self-exclude than donors who did not perceive a risk (Gaynor et al., 1989b).
326 ~ AIDS: THE SECOND DECADE Almost half (47 percent) of seropositive donors in another study reported by Williams assumed that the screening tests used by blood collection organizations could detect all contaminated donations and would ensure that their blood, if infected, would not be used for transfusion.37 Williams suggests that the pamphlet on self-exclusion provided by the American Red Cross may present comprehension problems, especially for Hispanic donors. Other researchers have posited that higher rates of infection among minority donors may reflect a disproportionate level of misunder- standing as well as a disproportionate background prevalence of infection in these subpopulations (Ward et al., 198Sa). Studies that identify the most effective materials to communicate the criteria, mechanisms, and reasons for self-deferral are clearly needed. The Food and Drug Administration is currently sponsoring a research project to develop and test such materials.38 There is also a need to determine the efficacy of other modes of communication, such as posters listing the risk behaviors displayed in waiting areas, or the use of audiocassettes (especially for donors whose first language is not English) or videotaped presentations. Studies designed to examine specifically the effectiveness of con- fidential unit exclusion (CUE) indicate that donors who exclude their donation through the CUE option are more likely to be HIV antibody- positive than are donors who indicate that their blood should be safe for transfusion (Nusbacher et al., 1986; Gaynor et al., l989b). However, CUE is not completely effective. Cleary and colleagues (1988) found that, among the HIV antibody-positive donors in their study, most ir~di- cated that their blood could be used for transfusion. Subsequently, most of the men in the study reported risk behavior even though they did not self-exclude. Among HIV-seropositive women who participated in the study, 92 percent directed their blood for transfusions, and more than half had no identified risk factor. Other studies report variation in self- exclusion rates by risk factors, with homosexually active males being the most likely to remove their donation from the transfusion pool (Gaynor et al., 1989b). Vanations in the CUE process itself may also affect its success in appropriately excluding donations. L.oicarlo and coworkers (1988) found that seropositive donors were more likely to self-exclude when either a confidential ballot or a bar code was used than when the 37Alan E. Williams, American Red Cross, Jerome H. Holland Laboratory, personal communication, April 30, 1990. 38Donna Mayo, American Institutes for Research, personal communication, May 4, 1989.
BLOOD SUPPLY | 327 CUE process involved a callback procedure.39 CUE procedures are often difficult for donors to understand, and one study indicated that fewer than 5 percent of donors understood the purpose of the CUE (Leitman et al., 19891. The most effective CUE mechanisms need to be identified if this process is to add significantly to the safety of the blood supply. The Inappropriate Use of Blood Collection Agencies for HIV Testing From the beginning of HIV antibody testing, blood centers have been concerned that some people will give blood in order to be tested rather than using alternative testing sites. In fact, Leitman and coworkers (1989) and Williams and colleagues (1987) found that approximately one-quarter of seropositive donors had donated in order to undergo HIV antibody testing. Blood donation centers were preferred because of the stigma associated with these other test sites. In a study by Doll arid coworkers (1989), fewer seropositive donors (6 percent) reported using blood collection organizations for HIV testing, but 17 percent were unable to identify another testing site. Because there will probably continue to be some individuals at risk for HIV infection who donate blood as a way of being tested, every effort should be made to reach these donors and refer them to alternative testing sites or to ensure that they use CUE if they elect to donate blood. A survey in Wisconsin found lower rates of infection among donors in communities that provided readily accessible testing and counseling at alternative sites (Snyder and Vergeront, 1988~.4° Referral networks to alternative testing sites that are consistent with the needs of the donor may also decrease the inappropriate use of blood collection organizations for testing. RESEARCH TO IMPROVE THE EXISTING SYSTEM This section summarizes the committee's recommendations for a research agenda in this area and identifies both general and specific issues for further attention. However, the recommendations that follow are not intended to be an exhaustive enumeration of suitable research topics. Rather, the general categories of research provide a point of departure 391-he self-excluding donors using either the bar code or ballot were more likely than the total sample (1.15 percent versus 0.033 percent) to be Westem blot positive. 40It should be noted, however, that Wisconsin has very low rates of HIV infection. Of the 197,751 units of brood donated between April 1, 1985 and December 31, 1987 in communities with alternative testing programs, 4 were found to have antibodies to HIV. Of the 182,720 units donated during this period in communities without alternative counseling and testing sites, 9 were found to be antibody positive (Snyder and Vergeront, 1988).
328 ~ AIDS: THE SECOND DECADE for what the committee hopes will become a continuing effort to identify areas and problems to which the social and behavioral sciences can make a meaningful contribution and to be a dialogue that cuts across the venous disciplines that can bring expertise (empirical and theoretical) to bear on the behavioral mechanisms for maintaining an adequate supply of safe blood for this country. Although much previous research on donor behavior points to po- tentially useful strategies to improve donor recruitment as well as donor screening, additional research is needed that is specific to the context of AIDS and that reflects the evolving nature of the epidemic. The next iter- ation of research on intervention strategies is likely to require on the one hand more tightly controlled methodologies and on the other hand more far-reaching, imaginative approaches to help donors who are at risk to self-defer and to encourage those who are not at risk to donate regularly. Moreover, effective strategies for recruiting and retaining safe donors from different subgroups of the donor population need to be established. Previous efforts have used the theories and methods of marketing; recruit- ment drives have surveyed community structures for potential groups of donors and sites for blood collection, segmented populations, and targeted drives to specific subgroups. Now, in the light of the AIDS epidemic, there is a need to assess whether the theories and tools of marketing and other relevant business-related areas can be applied to the development of recruitment programs that take into account current needs and HIV transmission. The need to evaluate new programs will continue. The specific research efforts proposed here would take either a cor- relational or experimental approach. Correlational studies would be ap- propriate to explore questions for which control over the independent variable of interest is not possible. Questions that might be investigated by correlational methods include the following: How do donors decide to designate their units "not for transfusion" on the CUE form? How can misunderstandings regarding the procedure be corrected? Why do some donors with identifiable risk factors continue to donate? How many donors without risk factors incorrectly indicate that their blood should not be used for transfusion, and why do they do so? Areas that would be amenable to expenmental research include new recruitment techniques, alternative formats (computer-assisted, audio- taped or videotaped) for presentations of risk information and health screening, and various educational programs in schools designed to in- crease general knowledge about risk factors and the importance of do- nation to the community. Exploration of recruitment techniques could evaluate the impact on donation of various incentives and motivational
BLOOD SUPPLY 1 329 factors, different recruiters, and different structural formats for the dona- tion process itself. Impacts should be assessed considering both first-time and repeat donors. Several methodological issues must be considered in assessing cur- rently available data on donor behavior and in designing future research. One of the methodological limitations of existing studies that makes their interpretation so difficult is the absence of control groups. For example, studies on the use of CUE have largely relied on samples of seropositive donors. Much less is known about how seronegative donors have ap- proached this self-exclusionary mechanism, and yet it is a small subset of this population the infected seronegative donor who is in the "window" between acquisition of infection and the development of an immunologic response for which the CUE was designed. Changing current sampling strategies could improve our understanding of these protective proce- dures, but additional work is needed For example, the failure to separate first-time and repeat donors has made it difficult to assess the relative risk of directed versus volunteer donations. At the heart of intervening to protect the blood supply is the problem of understanding risk perceptions. If we cannot help donors to appreciate behaviors that may have put them at risk in the past, we will have compromised our ability to prevent further transmission. Recent studies of donors who are labeled as homosexual but report sexual contact with both men and women highlight the need to separate bisexual men from gay men in data analyses. Our capacity to elicit accurate data is limited and will require significant resources and sustained attention (see Chapter 6 of this report). Refining intervention tools calls for improvement in the measurement of motivational factors associated with donation. Vague conceptualiza- tions of factors such as social pressure, internal incentives, and the like, have precluded the development of sound understanding of the impact of these factors on appropriate and inappropriate donation. Protecting the blood supply requires accurate, up-to-date informa- tion. Unfortunately, much of the available research on blood donation processes and donors was published prior to the AIDS epidemic and is therefore of questionable relevance to the current situation. In addition, much early work was calTied out by local blood collection organizations, largely to guide their own efforts; their findings, when reported, were brief. Important details, such as research design, sampling, and response rates, are often missing. Even when the details of design and analysis are available, the quality of the work varies greatly, and generalizations are difficult to make. Behavioral research expertise has not been strongly
330 ~ AIDS: THE SECOND DECADE represented in surveys of donor populations. As additional behavioral research is called for, the need for such expertise increases. Progress in solving current donor-related problems depends on a cadre of experienced researchers. In addition, training in how to conduct surveys of donor pop- ulations is needed. Most studies have looked at donors and nondonors at one point in time such cross-sectional efforts are not suited to under- standing motivations for donation, repeat donation, and exclusion. Thus, the committee finds there is a need for additional, well-designed research that takes current conditions into account. These studies are needed to improve our understanding of the factors that influence both the quantity and quality of blood donations. At present, considerable pressure is being placed on recruitment, screening, and collection personnel for the efficient "production" of units of blood. This pressure reflects both the need to maintain an adequate supply of blood and the need to keep blood collection costs to a min- imum. Added to this pressure is the countervailing emphasis on blood safety with its focus on screening and defemng at-risk donors. Recon- ciling these seemingly contradictory objectives will require continuing efforts and innovative strategies. Methods to develop a total "community responsibility" system that uses no pressure tactics, rewards, or incentives could contribute to blood safety and a greater probability of intrinsically motivated donatior~, which, as noted earlier, holds considerable promise for continued donorship. To increase the blood supply, the committee recommends that: · blood collection organizations prepare ant! deliver (in cooperation with the mass media) clear and accurate information concerning both the need for donation and the absence of health risks from donation; · the National Heart, Lung, anti Blood Institute support research on the design, systematic testing, and imple- mentation of new methods for attracting healthy first- time donors, retaining and encouraging repeat dona- tions, and enlisting the aid of repeat donors in donor recruitment; · blood collection organizations undertake to make the actual donation process as comfortable, friendly, and ef- ficient as possible through changes in scheduling proce- ~lures, physical accommodations, donor processing, and staff training;
BLOOD SUPPLY ~ 331 . . blood collection agencies, Public Health Service agen- cies, and community leaders employ innovative recruit- ment approaches among populations such as minority and certain age groups that traditionally have not been represented in the donor pool; and physicians and blood banks encourage autologous do- nation (i.e., predeposit of an individual's own blood) in cases in which surgery is anticipated (see later section on the appropriate use of blood). To improve the safety of the blood supply, the committee recom- mends thatch . . blood collection agencies strive for clearer communi- cation of the exclusion criteria to potential and actual donors; blood collection agencies work to increase donation by those who can safely give and abstention by those who are at even minimal risk through recruitment approaches that stress altruistic appeals rather than the use of com- petitions, incentives, and social pressure; and · the National Heart, Lung, and Blood Institute con- tinue its support for research to investigate why some donors with identifiable risk factors continue to donate while others without risk factors inappropriately exclude themselves. REDUCING THE RISK OF HIV INFECTION THROUGH APPROPRIATE USE OF TRANSFUSED BLOOD AND BLOOD COMPONENTS In addition to focusing on the donor to reduce the risk of HIV infection from transfused blood, strategies to reduce HIV infection can also focus on decreasing the patients' exposure to blood and blood components that have been collected from over individuals.42 Reducing the exposure of potential transfusion recipients to donated blood can be accomplished in 4iThe committee's recommendations are consistent with the World Health Organization's guidelines for the recruitment of safer donors (1.1, 1.2, 1.3) provided in the 1989 "Consensus Statement on Ac- celerated Strategies to Reduce the Risk of Transmission of HIV by Blood Transfusion" (World Health Organization, 1989). 42The risk of HIV infection is estimated to increase linearly with the volume of blood transfused; that is, the less blood transfused, the lower the risk of HIV infection (Curnming et al., 1989).
332 ~ AIDS: THE SECOND DECADE several ways, depending on the circumstances that prompt transfusion. In principle, these approaches involve more appropriate use of blood products by decreasing the unnecessary use of blood and blood compo- nents, increasing autologous donations, reducing the need for transfusion, and inactivating viruses that may be present in blood products. Educat- ing physicians and their patients and modifying behavior are necessary to achieve these goals. This section presents background information on practices and trends in blood utilization, potential points for reduc- ing transfusion exposure (with an emphasis on changing the behavior of prescribing physicians and patients who may be recipients), and the committee's recommendations for further research. Trends in Bloocl Utilization In recent years, blood centers have encouraged a shift from the transfusion of whole blood to transfusion of the specific component needed. This trend is considered sound medical practice and had the added benefit that a single donation could be used to treat as many as four different patients, thus relieving some of the strain on the blood supply. Currently, only 10 to 20 percent of transfusions are given as whole blood; the other 80 to 90 percent of donations are split into two or more blood components (red blood cells, platelets, leukocytes, or fresh-frozen plasma). The benefit of the trend away from transfusion of whole blood has been that patients receive the specific component they need and are not exposed to other components unnecessanly. A drawback of this practice, however, is that two to four patients may be exposed to blood components from one donation. The venous blood components are used for different purposes. Packed red blood ceils are generally used for chronic blood loss and anemias or in combination with saline or a colloid supplement for acute intraoperative or traumatic blood loss. Platelets are used for a variety of acute and chronic platelet deficiency conditions, including iatrogenic thrombocytopenias associated with cancer chemotherapy or with massive intraoperative blood loss, especially dunng cardiovascular surgery. To achieve adequate therapeutic levels, platelets derived from regular blood donations from several donors are pooled, thus multiplying the risk of exposure. An alternative to pooling donations from several donors is the collection of larger quantities of platelets from a single donor through plateletapheresis, which selectively removes only platelets. Leukocytes are mainly used to Heat severe infections in patients with leukopenias associated with chemotherapy. Leukocytes may also be denved from regularly donated blood or from single donors through leukopheresis.
BLOOD SUPPLY ~ 333 Fresh-frozen plasma is used in a number of ways, some of which may not be medically indicated. The most appropriate use of fresh- frozen plasma is to correct certain clotting factor deficiencies when the factor is not present in other blood products. Yet fresh-frozen plasma is often given simply to expand blood volume when other, stenIe volume expanders could be used instead. It is also common for fresh-frozen plasma to be given with a transfusion of red blood cells to reconstitute whole blood. The only possible benefit of such a practice might be an enrichment of clotting factors. However, the practice is often used when there is no therapeutic justification. Moreover, the benefits of such concomitant transfusion have not been established (Snyder, Gottschall, and Menitove, 19861. This practice also increases the risk of infection by exposing the recipient to two donors instead of one. There is evidence that blood transfusion utilization in the United States has been affected by concern over the risk of HIV transmission. Prior to the AIDS epidemic, national surveys revealed that transfusions of blood and blood components doubled between 1971 and 1980 (National Heart, Lung, and Blood Institute, 1972; Surgenor and Schnitzer, 1985~. A shift in this trend was observed between 1980 and 1985 (inclusive) in four sets of U.S. hospitals that together accounted for 4.8 percent of red blood cell transfusions in the United States in 1980 (Surgenor et al., 19881. Total red blood cell transfusion rates (total red blood cell transfusions per 1,000 hospital admissions) increased between 1980 and 1982 but remained nearly constant between 1982 and 1985. Plasma transfusion followed a similar pattern. In contrast, total platelet transfusion rates continued to increase by a total of 76 percent over the six-year period. Thus, the AIDS epidemic may have been a moderating factor in the use of red cells and plasma, but any impact on platelet transfusion rates is not apparent. An increasing demand for platelets dunng the period, however, may have obscured any moderating effect. Under certain conditions, patients can predeposit their own blood for transfusion during elective surgery. Such transfusion is referred to as "autologous," in contrast to transfusion of blood from other donors ("homologous"~. Before 1985, autologous blood transfusions were rarely used, and many blood centers in the United States did not have proce- dures for handling predeposited blood. From the perspective of the HIV epidemic, the infrequent use of autologous transfusion is regrettable. Autologous blood transfusion would have been especially beneficial between 1978 and 1985 when the prevalence of HTV in the blood supply was greatest but before a specific test was available to screen donor blood. Surveys conducted between 1980 and 1985 show an increase in
334 ~ AIDS: THE SECOND DECADE auto~ogous blood transfusions (Surgenor et al., 1988~. However, even after recognition of the dangers HIV presents to transfusion recipients, autologous blood transfusions were underutilized. Among 18 university hospitals surveyed in 1986, only 0.9 percent of total transfused red cell units were autonomous, when as much as 10 percent of such transfusions could have been made using autologous donations (Toy et al., 19871. Since then, the percentage of autologous units transfused at these same hospitals has increased (to 1.3 percent in 1987 and 2.6 percent in 1988), but the rate showed insignificant change in 1989 (Toy, 1989~. Thus, predeposited blood is now used in only one-quarter of the surgeries in which it could be used. Because transfusion with autologous blood is the safest form of transfusion, its infrequent use warrants further attention, as do methods to reduce inappropriate use of transfusions of blood and blood components. Reducing Transfusion Exposure Decreasing Unnecessary Use of Blood Products In 1985 the Office of Technology Assessment (1985) reported to Congress that both the suppliers and users of blood agreed that blood was often overused or used inappropnately. The report indicated, however, that suppliers and users differed in their assessment of the extent to which blood was misused and in their suggestions for promoting more appropr~- ate use. At present, there are no absolute standards or criteria regarding the appropriate use of blood and blood components. In the absence of such standards, it is difficult to determine with certainty whether trans- fusions are given appropriately. National data on transfusion practices, whether appropriate or inappropnate, do not exist. Nevertheless, a num- ber of studies on a more limited scale have audited transfusion practices and support the contention that some transfusions of red cells, platelets, and plasma are, indeed, inappropriate and could be reduced. For example, it has been common practice to postpone surgery or give preoperative blood transfusions to patients who have a hemoglobin level of less than 10 grams per deciliter (gm/DI) or a hematocnt of less than 34 percent. Using these Sterna, Stehling and Esposito (1987) found that 19 percent of all red cell intraoperative transfusions were not in- dicated. In addition, data from studies of Jehovah's Witnesses (Carson et al., 1988) who refuse transfusion because of religious convictions re- vealed no excess morbidity or mortality among patients who underwent surgery with hemoglobin levels of as low as ~ gm/DI. In another study, Tartter and Barton (1985) found that 25 percent of red cell units given
BLOOD SUPPLY ~ 335
336 ~ AIDS: THE SECOND DECADE recipient to two donors. Blumberg and colleagues (1986), however, have found suspect the assumption that this practice is of benefit to the patient. A consensus development conference, sponsored jointly by NIH's Office of Medical Applications of Research and the National Heart, Lung, and Blood Institute (1985) has stated that use of fresh-frozen plasma as a volume expander or to reconstitute red blood cells has no demonstrated benefit to the patient and unnecessarily exposes the recipient to additional donors. The extent to which fresh-frozen plasma is misused is unknown but is expected to be high. In one retrospective audit of transfusion practices in a hospital in Minnesota, 17 percent of fresh-frozen plasma transfusions were questionable, and an additional 11 percent were found not to be indicated (Coffin, Matz, and Rich, 19891. Another study conducted at the Puget Sound Blood Center in which all orders for fresh-frozen plasma have been audited by the blood bank for years showed that 20 percent of the fresh-frozen plasma requests in 1988 were considered not to be indicated (Price, 19891. Increasing Autologous Donation Autologous blood is the safest source of blood for transfusion because there is no possibility of transfusion reactions (as a result of blood group incompatibility) or of acquiring an infectious agent. The use of autologous blood reduces or may even eliminate the need for homologous blood from other donors. However, despite the benefits associated with the use of autologus blood, it has not beer universally adopted. Barriers to increased use of autologous donation include insufficient knowledge about the procedure among surgeons (Strauss et al., 1988), a failure to incorporate the procedure into standard preoperative routines, and unnecessarily rigid eligibility cr~tena adopted by many blood collection organizations (Anderson and Tomasulo, 19881. Patient ineligibility to donate also limits autologous blood use to some extent. In a study of 180 candidates for autologous donation (Kruskall et al., 1986), 47.8 percent were defected at least once, and 25.5 percent of attempts to use only autologous blood were abandoned because of deferral. Of those who were able to predeposit, 36.9 percent used only autologous components, and almost two-thirds used no homologous blood. Several successful Interventions have increased the use of autologous donation by focusing on physician education and improving the system so that predeposited blood can be gathered, stored, and delivered when needed (Kruskall et al., 19861. For example, at the Beth Israel Hospital in Boston, blood bank personnel now review the surgical schedule, and,
BLOOD SUPPLY ~ 337 if the scheduled surgery is two or more weeks away, they initiate the pro- cess of autologous donations (KIuskall et al., 19861. In other successful programs, surgeons instruct their office staff to incorporate autologous donation into routine preoperative procedures. When possible, surgery is scheduled four weeks later to allow time for donation. Despite these successes, predeposit~ng blood is still underutilized, pointing to the need for better application of mechanisms known to promote autologous do- nation as well as research to develop more effective ways of increasing autologous transfusion rates. For planned surgical procedures that are expected to result in suffi- cient blood loss to require transfusion, autologous transfusion strategies should be considered. The options for autologous transfusion are several: preoperative autologous blood donation, perioperative blood salvage, and acute normovolemic hemodilution (National Blood Resource Education Program, 1990 ). Each of these strategies can be used alone or in com- b~nation to reduce or eliminate the need for homologous blood. Preoperative Autologous Blood Donation. A candidate for pre- operative donation is a patient who has two or more weeks before a scheduled surgery, who is healthy, and who has a hemoglobin level of 11 gm/Dl (hematocrit of 33 percent) or higher. Patients undergoing orthopedic surgical procedures, for example, such as elective total hip replacement or scoliosis repair, are often ideal candidates for autologous donation. For patients who need more immediate surgery, the benefit of decreased exposure to homologous blood should be weighed against the risk of delaying surgery for the time needed for preoperative donation. Even elderly and pediatric patients Carl successfully predeposit blood. Autologous donations should not be routinely encouraged for pregnant women because transfusion is rarely needed during a normal delivery. Women with placenta previa,43 however, are highly likely to need a trans- fusion and can be encouraged to predeposit blood (Herbert, Owen, and Collins, 1988; McVay et al., 19891. Despite the benefits of autologous donation, there are practical con- sideratior~s that must be addressed if its use is to be maximized. The relatively short shelf life of red blood cells (approximately one month) limits the time available between donation and use of blood unless they are frozen and stored. The optimal donation period begins four to six weeks before surgery. Because most patients are able to donate once a week, three or more units can usually be collected before surgery, espe- cially if the patient also takes a therapeutic dose of oral iron. Although 43 Placenta previa, a form of placental development, often produces hemorrhage in the last trimester Of pregnancy, particularly during the eighth month.
338 ~ AIDS: THE SECOND DECADE many blood centers maintain autologous donor programs for long-term storage of frozen red blood cells, for practical reasons these programs are usually limited to patients with very rare blood types. Autologous donor programs for frozen red blood cells for the general population have thus far usually failed because of logistic and cost considerations (Meryman, 1989). Perioperative Blood Salvage. This form of autologous donation involves the collection and reinfusion of the patient's own blood during or after surgery (Hartz, Smith, and Green, 19881. It is especially beneficial in cases in which preoperative donation is impossible or inadequate and during procedures in which large amounts of blood are lost but can be salvaged. It is not appropriate for procedures with little blood loss or for patients with infection or malignant tumors (Amencan Medical Association, Council on Scientific Affairs, 19861. The amount of blood recovered in this manner is small, usually not exceeding one or two units. Thus, although salvage may provide some benefit, its potential is not nearly as great as that of predonation. Acute Normovolemic Hemodilution. By this procedure, a portion of the patient's blood is removed before surgery and is replaced with nonblood solutions. The result is hemodilution and a decrease in the viscosity of blood and changes in several other physiologic parameters during surgery (American Medical Association, Council on Scientific Affairs, 19861. At the end of surgery, the blood collected from the patient before surgery is reinfused. Because the blood lost during surgery is relatively dilute, the amount of red cells lost in a given volume is minimized. However, the safe lower limit of the hemodilution of hematocrit is unknown, and this uncertainty has limited the use of this procedure. Decreasing Patient Need for Blood Products Another strategy for reducing exposure to homologous blood involves shortening the patient's bleeding time or enhancing the patient's own red blood cell production. Desmopressin acetate has been shown to reduce blood loss in patients undergoing complex cardiac surgery (Salzman et al., 1986), and the hormone erythropoietin call substantially increase red blood cell production in certain patients with chronic anemia. Recent reports, for example, indicate that many chronic renal failure patients on hemodialysis who are transfusion dependent can maintain adequate hemogiobin~ematocnt levels with erythropoiet~n treatment alone (Es- chbach et al., 1989; Zanjani and Ascensao, 1989~. The use of erythro- poietin in chronic renal failure can reduce red blood cell transfusion requirements overall by as much as 2 to 3 percent. Other potential uses
BLOOD SUPPLY ~ 339 of erythropoietin have not been fully explored, but one use might be to increase preoperative red blood cell levels in anemic patients. Additional uses of this kind could theoretically reduce nationwide red blood cell transfusion requirements by as much as 5 to 10 percent. The cost of the hormone, however, may limit its applicability for this purpose. Inactivating Viruses Only two strategies could completely eliminate all risk of infection through blood transfusions: removing or inactivating viruses from blood and blood components, and using blood substitutes. Using blood sub- stitutes would have the additional benefit of alleviating shortages in the blood supply. Unfortunately, neither an effective inactivation method for all blood products nor an effective blood substitute is on the immediate horizon. Viruses present in clotting factor concentrates can now be inac- tivated either by heat or by solvent detergent treatment (Horowitz, 1987), but viral inactivation is not yet viable for whole blood, fresh-frozen plasma, or such cellular components as packed red blood cells, platelets, and leukocytes (Horowitz, 1987~. Therefore, efforts to reduce the risk of transfusion-transmitted HTV infection must continue to rely on donor screening and on modifying physician practices and patient behavior. Modifying Physician Behavior Few studies have been done to date on modifying physician practices regarding transfusion. Nonetheless, the literature on modifying physi- cian behavior in other areas of medical practice suggests that modifying physician transfusion practices will probably also require more sophisti- cated interventions than simply providing pnnted materials or continuing education lectures (Soumera~ et al., 1987~. Reliance on such approaches reflects a commonly held belief that changes in a physician's behavior and attitudes will follow changes in knowledge, but the availability of printed infonnation may not lead to new knowledge or in turn to changes in behavior. Several studies indicate that the provision of classroom tutorials arid written educational matenals, primary educational tools in physician training, has little impact on some physician behavior (Inui, Yourtee, and Williamson, 1976; Avom and Soumerai, 1983; Schaffner et al., 1983; Maiman et al., 1988~. Moreover, there may be dissociation between knowledge and behavior. In studies of physician prescribing practices, innovative printed materials led to changes In a physician's knowledge and attitudes but were not accompanied by changes in behav- ior (Soumerai and Avom, 1984~. These studies do not negate the role of print-based educational matenals as an integral component of more
340 ~ AIDS: THE SECOND DECADE effective strategies, but they do show that print information alone cannot be relied on to produce change (Soumera~ and Avorn, 19841. Giving physicians feedback about their behavior, often in conjunc- tion or comparison with accepted guidelines, has been used to induce behavioral change. This approach assumes that feedback pertaining to the physicians' own cases will motivate them to modify their behavior to adhere more closely to recommended practices. Studies of the effect of feedback on physician behavior, however, have had mixed results (Avorn and Soumerai, 1982; S. A. Schroeder et al., 19849. This inconsistency may reflect the manner and context in which feedback is given in various studies. The length of time between the behavior and the feedback or the extent to which feedback is individualized may influence its potential impact. Soumerai, McLaughlin, and Avom (1989) noted that feedback programs are more often administrative rather than educational in that they focus on criticism and correction of errors rather than on modifying beliefs about appropriate medical practice and changing behaviors. In one successful intervention to improve physician performance of colorectal cancer screening, physicians given feedback regarding their individual performance did better than those who did not receive feedback (Winick- off et al., 19841.44 It has been suggested that the effectiveness of feedback might be enhanced if opinion leaders in the medical community and the physicians to be monitored all participate in program design (Tierney, Hui, and McDonald, 1986~. Hospital audits of blood usage, such as those required by the Joint Council of the Administration of Healthcare Organizations (ICAHO) could provide valuable information for feedback to physicians as part of transfusion intervention programs (Coffin, Matz, and Rich, 19891. These audits have provided the impetus for studies of the impact of prospective or daily review systems on transfusion practices in a number of hospitals. Prospective review involves an audit prior to transfusion, thus offering an opportunity to provide immediate feedback to the physician, coupled with education at the point of requesting blood and intervention if requests are not appropriate. Prospective audits in conjunction with transfusion 44 An educational program to improve physician perfollllance in colorectal cancer screening was imple- mented in a department of internal medicine and evaluated. The program included: 1) an educational meeting for the department's physicians at which a standard of care for colorectal cancer screening was conveyed (the standard included a digital examination and stool test for occult blood to be obtained at all initial or periodic check-ups of patients over age 40); 2) a follow-up meeting at which the rate of adherence to the standard by the physicians as a group was presented; and 3) for a subset of the physicians, an experiment in which physicians were given monthly individual feedback comparing their performance to that of their peers. The results showed that the physicians receiving individu- alized feedback significantly improved in adherence when compared with those who were not given feedback; behavior changes persisted at 6 and 12 months after intervention.
BLOOD SUPPLY ~ 341 education led to a 50 percent reduction of ffesh-frozen plasma use in one study (R. R. Solomon, Clifford, and Gutman, 1988) and reductions in platelet use of 14 percent (McCullough et al., 1988) and 56 percent (Simpson, 1987) in two others. Daily review systems involve retrospec- tive review of transfusion, which may also affect transfusion practices. In one study, daily audit reviews reduced inappropriate red cell transfusions from 37 to 10 percent (Giovaneui et al., 19881. Similar audits decreased fresh-frozen plasma use by 77 percent (Shanberge, 1987~. Personalized, face-to-face educational interventions appear to give the best results in modifying physician behavior. In studies involving physician prescription practices, personal intervention resulted in signifi- cantly improved decisions when compared with education limited to print materials (Avorn and Soumerai, 1983; Schaffner et al., 19831. Face-to- face interventions also increased the effectiveness of physicians' efforts to educate their patients on adherence to medication (Madman et al., 19881. There is some evidence that direct intervention with physicians results in greater behavioral change than can be achieved by training faculty who ir1 turn pass training messages on to physicians under their supervision (Kramer, Ber, and Moore, 1987~.45 Once behavior has changed, it is important to reinforce the new practices physicians adopt. Some researchers have observed that changes in physician behavior diminish after training programs are removed (Pat- terson, Fried, and Nagle, 1989~. Reminders, such as checklists affixed to patient charts, appear to increase physician compliance (McDonald et al., 19841. Such reminders are more effective if they are provided close to the time at which the physician will engage in the targeted behav- ior. For example, in a study by Tierney, Hui, and McDonald (1986), reminders attached to patient charts were more effective in stimulat- ing behavioral change than general reminders of recommended practices given at monthly intervals. With regard to transfusion practices, check- lists for preparing patients for elective surgery could prompt physicians 45 Medical students and physicians (who also would later be used to tutor a group of medical students) participated in an interpersonal skills workshop on supporting behaviors in the medical interview. The workshop consisted of ten 90-minute meetings held twice a week for five weeks. The workshops taught openness, flexibility, and empathy among group members. `'The assumption behind these objectives was that developing these reactions in the group members toward each other would allow the students to transfer the use of these skills toward patients." (p. 906). The topics covered in the meetings were: patient admission, diagnosis of a life-threatening disease, death and dying teamwork, uncertainty, and chronic disease. Time was spent role-playing and in group discussion. The results showed that both medical students and physicians who participated in the workshop showed a significant reduction in rejecting behaviors (i.e., ignoring emotions, not listening, or evading eye contact during patient in- terviews). However, a group of students who were taught by physicians who had been through the workshop did not show a reduction in rejecting behaviors.
342 ~ AIDS: THE SECOND DECADE to consider autologous donation and also provide a summary of dona- tion guidelines. Similarly, request forms for transfusion could prompt physicians to consider the appropriateness of their request by including standard criteria for transfusion (Avorn et al., 19881. Modifying Patient Behavior Patients potential recipients of blood products have not been included in research on transfusion practices, and that absence has produced gaps in information that need to be filled. Undoubtedly, patient concerns re- garding transfusion-~ansmitted HIV have contributed to the changes seen in blood use (Surgenor et al., 1988~. Pressure from patients, however, depends on the individual patient's knowledge of the issues. Thus, pa- tients could be educated regarding the risks and benefits of transfusion so as to play a more active part in decisions regarding transfusion practices. For example, they could be made aware of the potential risks associated with directed donation. Most important, patients could be more effec- tively taught about the advantages of autologous donation so that they might be more willing to endure its "costs" the slight discomfort of blood donation, the time and travel that may be required to donate, the postponement of surgery when medically appropriate, and the necessity of taking oral iron as prescribed. The committee recommends that agencies of the Public Health Service sponsor the development, systematic testing, and implemen- tation of transfusion-related intervention and education programs to facilitate change in physicians' attitudes and behaviors with regard to: encouraging healthy patients to donate blood; encouraging autologous donation where metlically ap- propriate; · eliminating the unnecessary use of blood and blood com- ponents; and employing appropriate procedures (e.g., perioperative blood salvage, use of erythropoietin) that reduce the need for transfusions . Directions for Future Research Determining the appropriateness of blood and blood component use re- quires that standards or criteria be established against which to measure 46The committee's recommendations are consistent with the World Health Organization's (1989) con- sensus statements (3.1, 3.2, 3.3) concerning Me use of fewer transfusions.
BLOOD SUPPLY | 343 current practices. To develop such standards requires more accurate data on the extent of such use (to discern trends or patterns), together with standardized information on the medical history of the candidates for blood transfusion that make up this data base. Currently, trends in transfusion practices are derived from surveys of individual hospitals in discrete geographic locations that collected data (Surgenor et al., 1988~. To detect patterns across locations (which later may be used to target ed- ucation programs) requires careful consideration of how the hospitals are selected and the types of data that are being collected. It would be helpful to know, for example, whether transfusion practices vary across different types of health care facilities (e.g., university-affiliated hospitals, public institutions). Similarly, data are needed on patterns of use for the differ- ent health problems for which transfusions may be ordered. (At least one ongoing national study examining blood use in first-time coronary artery bypass surgery suggests wide variation in transfusion practices for this cardiovascular procedure [Goodnough et al., 1988~.) Data that indicate changes in usage over time will also be needed to monitor blood use and the effectiveness of education programs. Data on autologous donation (Toy et al., 1987) have provided an impetus for educational efforts, such as the National Blood Resource Education Program. To achieve a more solid basis for the formulation of guidelines on appropriate blood use, the committee recommends that the Public Health Service sponsor research to monitor trends in transfusion practices nationally to permit evaluation of the appropriateness of blood and blood component utilization and to identify targets for change. It further recommends that the PHS develop and evaluate effective strategies for informing patients about the risks and benefits of transfusion. The burden of developing widely accepted standards of blood and blood component use largely rests with those individuals who are responsible for the supply and distribution of blood. Yet, the con- sumers of that blood (i.e., the patients) also require education regarding the conditions under which transfusion is necessary and the current need to balance concerns about safety and appropriate use. * * * * * * * ~ * * The enigma of silent, undetected HIV infection thus poses a particularly serious challenge for the biomedical and social/behavioral research com- munities in relation to the nation's blood supply. lThe progress achieved to date has come from the concerted efforts of a variety of scientists, who continue to confront the problem of securing an adequate supply of safe blood. Future research may not achieve the quantum leap in risk
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348 ~ AIDS: THE SECOND DECADE Edwards, P. W., and Zeichner, A. (1985) Blood donor development: Effects of personality, motivational and situational variables. Personality and Individual Differences 6:743-751. Eschbach, J. W., Egne, J. C., Downing, M. R., Browne, J. K., and Adarnson, J. W. (1987) Correction of the anemia of end-stage renal disease with recombinant human erythropoietin: Results of a combined Phase I and II clinical trial. New England Journal of Medicine 316:73-78. Eschbach, J. W., Kelly, M. R., Haley, N. R., Abets, R. I., and Adamson, J. W. (1989) Treatment of the anemia of progressive renal failure with recombinant human erythropoietin. New England Journal of Medicine 321:158-163. Evans, D. E. (1981) Development of intrinsic motivation for voluntary blood donation among first-time donors. Dissertation Abstracts International 42:3777. Evatt, B. L., Francis, D. P., McLane, M. F., Lee, T. H., Cabradilla, C., et al. (1983) Antibodies to human T-cell leukemia virus-associated membrane antigens in hemophiliacs: Evidence for infection before 1980. Lancet 2:698-700. Farrales, F. B., Stevenson, A. R., and Bayer, W. L. (1977) Causes of disqualification in a volunteer blood donor population. Transfusion 17:598~01. Ferrari, J. R., Barone, R. C., Jason, L. A., and Rose, T. (1985a) Effects of a personal phone call prompt on blood donor commitment. Journal of Community Psychology 13:295-298. Ferran, J. R., Barone, R. C., Jason, L. A., and Rose, T. (1985b) The use of incentives to increase blood donations. Journal of Social Psychology 125:791-793. Fischer, A., Pura, L., Smith, L., and Goldfinger, D. (1986) Safety and effectiveness of directed blood donation in a large teaching hospital. Transfusion 26:600(A611. Fishbein, M., and Ajzen, I. (1975) Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, Mass.: Addison and Wesley. Fisher, J. D. (1988) Possible effects of reference group-based social influence on AIDS-risk behavior and AIDS prevention. American Psychologist 43:91~920. Foss, R. D. (1983) Community nones and blood donation. Journal of Applied Social Psychology 13:28 1-290. Foss, R. D., and Dempsey, C. B. (1979) Blood donation and the foot-in-the-door technique: A limiting case. Journal of Personality and Social Psychology 37:58~590. Fowler, F. J., Jr. (1989) Evaluating special training and debriefing procedures for pretest interviews. In C. Cannell, L. Oksenberg, G. Kalton, K. Bischoping, and F. J. Fowler, eds., New Techniques for Pretesting Survey Questions. (mimeo). Final Report to the National Center for Health Services Research and Health Care Technology Assessment. Survey Research Center, University of Michigan and Center for Survey Research, University of Massachusetts. Fowler, F. J., and Mar~gione, T. W. (1990) Standardized Survey Interviewing. Newbu~y Park, Calif.: Sage. Freiburger, C. A., and George, W. R. (1988) It's as easy as 1, 2, 3: lst-time donors will come back. Transfusion 28:(Suppl. 61:55S(A551. Gaynor, S., Kessler, D., Berge, P., Andrews, S., and Del Valle, C. (1989a) Risk factors for HIV among New York blood donors in 1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9.
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350 ~ AIDS: THE SECOND DECADE Hughes, M. J., Winter, S. L., Perkins, C. I., Kizer, K. W., Capell, F. J., and Trachtenberg, A. I. (1989) Prevalence of HIV antibody among blood donors in California. New England Journal of Medicine 321 :97i975. Wyman, H. H., Cobb, W. J., Feldman, J. J., Hart, C. W., and Stember, C. H. (1975) Interviewing in Social Research. Chicago, Ill.: The University of Chicago Press. Imagawa, D. T., Lee, M. H., Wolinsky, S. M., Sano, K., Morales, F., et al. (1989) Human immunodeficiency virus Type 1 infection in homosexual men who remain seronegative for prolonged periods. New England Journal of Medicine 320:1458- 1462. Inui, T. S., Yourtee, E. L., and Williamson, J. W. (1976) Improved outcomes in hypertension after physician tutorials: A controlled trial. Annals of Internal Medicine 84:646~51. Jason, L. A., Jackson, K., and Obradovic, J. L. (1986) Behavioral approaches in increasing blood donations. Evaluation and the [health Professions 9:439 448. Jason, L. A., Rose, T., Ferrari, J. R., and Barone, R. (1984) Personal versus impersonal methods for recruiting blood donations. Journal of Social Psychology 123:139- 140. Kalish, R. I., Cable, R. G., and Roberts, S. C. (1986) Voluntary deferral of blood donations and HTLV-III antibody positivity. New England Journal of Medicine 314:1115-1116. Kaloupek, D. G., and Stoupakis, T. (1985) Coping with a stressful medical procedure: Further investigation with volunteer blood donors. Journal of Behavioral Medicine 8:131-148. Kaloupek, D. G., Scott, J. R., and Khatarni, V. (1985) Assessment of coping strategies associated with syncope in blood donors. Journal of Psychosomatic Research 29:207-214. Kaloupek, D. G., White, H., and Wong, M. (1984) Multiple assessment of coping strategies used by volunteer blood donors: Implications for preparatory training. Journal of Behavioral Medicine 7:35-60. Kelley, H. H. (1967) Attribution theory in social psychology. In D. Levine, ea., Nebraska Symposium on Motivation. Lincoln, Neb.: University of Nebraska Press. Kleinman, S., and Secord, K. (1988) Risk of human immunodeficiency virus (HIV) transmission by anti-HIV negative blood: Estimates using the lookback method- ology. Transfusion 28:499-501. Kotler, P., and Roberto, E. L. (1989) Social Marketing: Strategies for Changing Public Behavior. New York: The Free Press. Kramer, D., Ber, R., and Moore, M. (1987) Impact of workshop on students' and physicians' rejecting behaviors in patient interviews. Journal of Medical Education 62:90~909. Kruskall, M. S., Glazer, E. E., Leonard, S. S., Willson, S. C., Pacini, D. G., et al. (1986) Utilization and effectiveness of a hospital autologous preoperative blood donor program. Transfusion 26:335-340. LaQue, C., Bailey, G., Odell, T., Heal, J., and Nusbacher, J. (1982) Hemapheresis donors as volunteer recruiters. Transfusion 22:446(A431. Leibrecht, B. C., Hogan, J. M., Luz, G. A., and Tobias, K. I. (1976) Donor and non-donor motivations. Transfusion 16:182-189.
BLOOD SUPPLY ~ 351 Leitman, S. F., Klein, H. G., Melpolder, J. J., Read, E. J., Esteban, J. I., et al. (1989) Clinical implications of positive tests for antibodies to human immunodeficiency virus Type 1 in asymptomatic blood donors. New England Journal of Medicine 321:917-924. Levine, E. A., Gould, S. A., Rosen, A. L., Sehgal, L. R., Egne, J. C., et al. (1989) Perioperative recombinant human erythropoietin. Surgery 106:432~38. Lightman, E. S. (1981) Continuity in social policy behaviours: The case of voluntary blood donorship. Journal of Social Policy 10:53-79. Lima, V. M., and D'Amonm, M. A. (1985) Application of Fishbein and Ajzen's theory of persuasion to the recruitment of voluntary and periodic blood donors. Arquivos Brasileiros de Psicologia 37:11~119. Linden, J. V., Gregono, D. I., and Kalish, R. I. (1988) An estimate of blood donor eligibility in the general population. Vox Sang 54:9~100. Lipsitz, A., Kallmeyer, K., Ferguson, M., and Abas, A. (1989) Counting on blood donors: Increasing the impact of reminder calls. Journal of Applied Social Psychology 19: 1 057-1067. Loicano, B., Carter, G., Leitman, S. F., and Klein, H. G. (1988) Efficacy of various methods of confidential unit exclusion in identifying potentially infectious blood products. Transfusion 28(Suppl. 6):54S(A5 1~. London, P. (1970) The rescuers: Motivational hypotheses about Christians who saved Jews from the Nazis. In J. Macaulay and L. Berkowitz, eds., Altruism and Helping Behavior. New York: Academic Press. Maiman, L. A., Becker, M. H., Liptak, G. S., Nazanan, L. F., and Rounds, K. A. (1988) Improving pediatricians' compliance-enhancing practices. American Journal of Diseases of Children 142:773-779. Marrow, A. J. (1969) The Practical Theorist. New York: Basic Books, Inc. McBa~nette, L., Rosner, F., Blake, M. V., and Kahn, A. E. (1978) The rejected blood donor: Companson between a voluntary and municipal hospital. Transfusion 18:69-72. McCall, G. J., and Simmons, I. L. (1978) Identities and Interactions. Rev. ed. New York: The Free Press. McCullough, J., Steeper, T. A., Connelly, D. P., Jackson, B., Huntington, S., and Scott, E. P. (1988) Platelet utilization in a university hospital. Journal of the American Medical Association 259:241~2418. McDonald, C. J., Hui, S. L., Smith, D. M., Tiemey, W. M., Cohen, S. J., et al. (1984) Reminders to physicians from an introspective computer medical record. Annals of Internal Medicine 100:13~138. McVay, P. A., Hoag, R. W., Hoag, M. S., and Toy, T. (1989) Safety and use of autologous blood donation dunng the third tnmester of pregnancy. American Journalof Obstetrics and Gynecology 160:1479-1488 Mell, G. W. (1979) Research findings of Red Cross blood donor profile. Amencan Red Cross, Muskegon-Oceana Chapter. Menitove, J. E. (1989) The decreasing risk of transfusion-associated AIDS. New England Journal of Medicine 321:96~968. Meryman, H. T. (1989) Frozen red cells. Transfusion Medicine Reviews 3:121-127. Moore, S. B., ed. (1987) Transfusion-Transmitted Viral Diseases. Arlington, Va.: American Association of Blood Banks.
352 ~ AIDS: THE SECOND DECADE Moss, A. J. (1976) Blood donor characteristics and types of blood donations. In Vital and Health Statistics. DNEW 7~1533. Series 10, No. 106:1-19. Rockville, Md: National Center for Health Statistics. Murray, C. (1988) Evaluation of on-site cholesterol testing as a donor recruitment tool. Transfusion 28(Suppl. 61:56S(A59~. National Blood Resource Education Program. (1989) Transfusion Alert: Use of Autologous Blood. Ned Publication No. 89-3038. Bethesda, Md.: National Heart, Lung, and Blood Institute. National Blood Resource Education Program. (1990) The use of autologous blood: The national blood resource education program expert panel. Journal of the American Medical Association 263:414~17. National Heart, Lung, and Blood Institute (NHLBI). (1972) Summary report: National Heart, Lung and Blood Institute's resource studies. U.S. Department of Health, Education, and Welfare Publication No. (NIH) 73~16. Bethesda, Md.: U.S. Department of Health, Education, and Welfare. National Heart, Lung, and Blood Institute (NHLBI). (1988) AIDS and blood resources. Presented at the meeting of the Corrunittee on AIDS Research, National Academy of Sciences. Washington, D.C., December 22. Nelson, K. E., Vlahov, D., Margolick, J., and Bernal, M. (1989) Blood and plasma donations among a cohort of IV drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Newman, B. H., Burak, F. Q., McKay-Peters, E. H., and Pothiawala, M. A. (1988) Patient-related blood drives. Transfusion 28:142-144. Nichols? E. K. (1986) Mobilizing Against AIDS: An Unfinished Story of a Virus. Cambridge, Mass.: Harvard University Press. Nusbacher, J., Chiavetta, J., Naiman, R., Buchner, B., Scalia, V., and Herst, R. (1986) Evaluation of a confidential method of excluding blood donors exposed to human immunodeficiency virus. Transfusion 26:539-541. Obome, D. J., Bradley, S., and Lloyd-Griffiths, M. (1978) The anatomy of a volunteer blood donation system. Transfusion 18:458~65. Office of Medical Applications of Research (OMAR), National Institutes of Health. (1985) Consensus Conference: Fresh-frozen plasma indications and risks. Journal of the American Medical Association 253:551-553. Office of Medical Applications of Research (OMAR)? National Institutes of Health. (1987) Consensus Conference: Platelet transfusion therapy. Journal of the Ameri- can Medical Association 257:1777-1780. Office of Medical Applications of Research (OMAR), National Institutes of Health. (1989) Perioperative red cell transfusion: National Institutes of Health Consensus Development Conference. Transfusion Medicine Reviews 3:63-68. Office of Technology Assessment (OTA). (1985) Blood Policy and Technology. Wash- ington, D.C.: Office of Technology Assessment. Oswalt? R. M. (1977) A review of blood donor motivation and recruitment. Transfusion 17:123-135. Oswalt, R. M., and Zaclc, L. A. (1976) The motivation and recruitment of pheresis donors. Presented at the 29th Annual Meeting of the American Association of Blood Banks, San Francisco, October November 5.
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