AIDS The Second Decade (1990) / Chapter Skim
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5 AIDS and the Blood Supply
5 AIDS and the Blood Supply
Pages 289-358
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From page 289... ...
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)
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From page 290... ...
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.
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From page 291... ...
. antibody to the virus became available in March 1985, blood collection organizations added this serologic test to their screening procedures (CDC, 1985; Ward et al., 1986~.
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From page 292... ...
This decrease is due both to notification and exclusion of donors found to be positive for antibody to HIV and to success in donor selfexclusion 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
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From page 293... ...
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)
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From page 294... ...
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.
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From page 295... ...
There are other informational issues that blood collection organizations 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.
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From page 296... ...
, one of the federal institutions responsible for regulating the blood collection 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.
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From page 297... ...
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~.
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From page 298... ...
In deciding whether or not to obtain blood from other areas during periods of shortage, administrators of blood collection 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.
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From page 299... ...
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 Region, 1981; L~ightman, 19811.
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From page 300... ...
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)
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From page 301... ...
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.
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From page 302... ...
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
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From page 303... ...
Social Pressure Pressure to conform to the expectations of others may be a factor motivating blood donation (Condie, Warner, and Giliman, 1976; Drake, Finkelstein, and Sopolsky, 19821. The belief that social pressure increases donations certainly underlies the recruitment strategy of blood bank "drives" at various organizations or businesses.
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From page 304... ...
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.
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From page 305... ...
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.
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From page 306... ...
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.
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From page 307... ...
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.
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From page 308... ...
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.
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From page 309... ...
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 organizations 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.
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From page 310... ...
This initial contact is then followed by a lesser, more manageable request (e.g., one blood donation)
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From page 311... ...
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)
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From page 312... ...
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)
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From page 313... ...
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)
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From page 314... ...
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.
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From page 315... ...
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)
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From page 316... ...
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 donation experience.
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From page 317... ...
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.
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From page 318... ...
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.
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From page 319... ...
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 noninstitutionalized civilian population.
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From page 320... ...
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)
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From page 321... ...
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.
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From page 322... ...
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.
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From page 323... ...
In March 1983, blood collection organizations introduced the request for self-deferral of homosexual or bisexual men with multiple partners, a practice that resulted 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)
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From page 324... ...
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.
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From page 325... ...
These findings point to particular problems 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)
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From page 326... ...
Williams, American Red Cross, Jerome H Holland Laboratory, personal communication, April 30, 1990.
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From page 327... ...
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.
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From page 328... ...
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; recruitment drives have surveyed community structures for potential groups of donors and sites for blood collection, segmented populations, and targeted drives to specific subgroups.
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From page 329... ...
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.
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From page 330... ...
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 implementation of new methods for attracting healthy firsttime donors, retaining and encouraging repeat donations, and enlisting the aid of repeat donors in donor recruitment; · blood collection organizations undertake to make the actual donation process as comfortable, friendly, and efficient as possible through changes in scheduling proce~lures, physical accommodations, donor processing, and staff training;
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From page 331... ...
. blood collection agencies, Public Health Service agencies, and community leaders employ innovative recruitment 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 donation (i.e., predeposit of an individual's own blood)
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From page 332... ...
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.
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From page 333... ...
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~.
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From page 334... ...
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)
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From page 336... ...
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.
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From page 337... ...
For planned surgical procedures that are expected to result in sufficient 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 )
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From page 338... ...
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.
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From page 339... ...
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.
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From page 340... ...
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.
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From page 341... ...
, reminders attached to patient charts were more effective in stimulating behavioral change than general reminders of recommended practices given at monthly intervals. With regard to transfusion practices, checklists 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)
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From page 342... ...
The committee recommends that agencies of the Public Health Service sponsor the development, systematic testing, and implementation 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 appropriate; · eliminating the unnecessary use of blood and blood components; and employing appropriate procedures (e.g., perioperative blood salvage, use of erythropoietin) that reduce the need for transfusions .
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From page 343... ...
Data on autologous donation (Toy et al., 1987) have provided an impetus for educational efforts, such as the National Blood Resource Education Program.
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From page 344... ...
Journal of the American Medical Association 256:2378-2380. American Red Cross Blood Services, Los Angeles-Orange Counties Region.
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From page 345... ...
(1977) A descriptive characterization and comparison of blood donors and non-donors in a community blood program.
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From page 346... ...
(1988) Sociodemographic and behavioral characteristics of HIV antibody-positive blood donors.
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From page 347... ...
(1989) Behavioral determinants of blood donations among HIV-seropositive persons: A multi-center study.
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From page 348... ...
(1989a) Risk factors for HIV among New York blood donors in 1988.
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From page 349... ...
(1989b) Self-exclusion by HIV antibody positive blood donors.
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From page 350... ...
(1989) Prevalence of HIV antibody among blood donors in California.
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From page 351... ...
(1989) Clinical implications of positive tests for antibodies to human immunodeficiency virus Type 1 in asymptomatic blood donors.
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From page 352... ...
(1986) Evaluation of a confidential method of excluding blood donors exposed to human immunodeficiency virus.
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From page 353... ...
(1987) The progressive decrease in the proportion of blood donors with antibody to the human immunodeficiency virus (HIV)
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From page 354... ...
(1987) Junior high school student blood drive A community education program for non blood donors.
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From page 355... ...
(1978) A study of the conversion from paid to altruistic blood donors in New Mexico.
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From page 356... ...
(1988) Factors influencing aggregate level of blood donation.
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From page 357... ...
(1988a) Epidemiologic characteristics of blood donors with antibody to human immunodeficiency virus.
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From page 358... ...
Journal of Applied Social Psychology
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