In order to provide safe blood for donation, blood banks must test each unit for HIV as well as a number of other infections. Since banks thus obtain information on a donor’s HIV status, should this information be given to the donor? S N Misra explores this controversial issue

Over the years, the demand for blood transfusions has been on the increase the world over. Various critical disease conditions, road traffic accidents and other emergency and routine surgeries require safe blood transfusions. However, safe blood still remains out of reach of millions who require it. On June 14 every year, World Blood Donor Day is celebrated all over the globe. This day has been designated by the World Health Assembly to pay tribute to millions of people who selflessly donate this life saver on a voluntary, altruistic, unpaid basis, thereby saving the lives of many and improving the health of others.

Although more than 80% of the world’s population lives in the developing and transitional countries, only 45% of blood is donated by these countries of all the 81 million blood units that are collected globally every year. WHO recommends that 1-3% of a country’s population should give blood to meet the country’s need. Voluntary blood donation is being promoted as a key strategy all over the world for meeting this requirement. Governments and national blood transfusion services have joined hands with national Red Cross and Red Crescent societies, community based organisations, schools and colleges to increase the number of voluntary, regular blood donors.

National Blood Policy of India

In India, government regulations require all blood banks to be licensed and monitored for supply of safe blood. All donated blood is subjected to mandatory testing for HIV, hepatitis B, hepatitis C, malaria and syphilis. Any blood unit found to be positive for any of the mentioned infections is discarded. For HIV, only a single ELISA test is conducted for blood banking purposes and any blood unit found sero-positive on this single test is discarded. This is not a confirmation of HIV infection in the donor. Confirmation of HIV in an individual is through three tests repeated on the same blood sample. This confirmation is conducted at a Voluntary Counselling and Testing Centre (VCTC) separately established at various tertiary and district hospitals and NGO and private sector health facilities.

The existing policy of the Government of India envisaged revelation of HIV status only to result-seeking blood donors. This policy decision was taken in 2003 when there was a great need to encourage voluntary blood donation which was gradually picking up in the country. Moreover, there were chances of voluntary blood donors being discriminated against for their HIV-positive status. To avoid such stigma and discrimination, it was decided to reveal the result only to those donors who gave their written consent for the same.

A review of the existing policy was conducted by the National Blood Transfusion Council (NBTC) and National AIDS Control Board (NACB). As a consequence of this meeting, and with the approval of the National AIDS Control Board, amendments were made in the existing National Blood Policy Guidelines as follows:

• Sero-reactive blood donors may be called to the blood bank concerned for their counselling and confirmatory HIV test to defer their referral to the counselling and testing centres in the vicinity.
• The major blood banks are to be equipped with facilities for counselling and HIV test confirmation in sero-reactive donors.
• Blood banks collecting blood through organised camps to send their sero-reactive samples to government-recognised HIV testing laboratories for confirmatory HIV tests.
• An HIV/AIDS counsellor would be placed at all major blood banks, who would provide the pre- and post-test counselling to the HIV sero-reactive blood donors and adequate referral to RNTCP/ART /STI.
• Blood banks collecting less than 3000 units of blood per annum would not require any counsellor due to the low work load. In this context, adequate linkage needs to be established between these blood banks and the nearest major blood bank/voluntary counselling centre for referring the sero-reactive blood donors for HIV/AIDS counselling and confirmation of their HIV status.

The pros and cons of this approach

Since a majority of HIV infected persons across the globe, including India, are not aware of their HIV sero-status, disclosure of blood test results to the donor would greatly benefit the donor and the community. With antiretroviral treatment now available, the infected donor could go for further confirmation of infection and subsequent treatment. Since the donor would most likely be asymptomatic and may remain asymptomatic for a considerable number of years, this might be his/her only opportunity for knowing his/her HIV status. It would also most likely reduce further HIV transmission to the community as this donor would be more knowledgeable and aware about HIV and its transmission through the counselling that is offered with HIV testing.

On the negative side, it has been seen that the safest blood donors are voluntary, unpaid blood donors who donate blood for altruistic reasons, and blood-borne infections have been found to be the lowest among this group of donors. With an estimated 5.2 million infections in India, the prevalence in the adult population continues to be less than 1%. Therefore, with professional blood donation banned, the prevalence of HIV in healthy blood donors would also be low. So, while referring a donor with a positive test result to the nearest counselling and testing centre is certainly welcome, establishing full-fledged voluntary counselling and testing centres in blood banks would amount to wasteful expenditure.

Besides, the main function of a blood bank is to ensure a safe blood transfusion service. According to available data, about 2% of AIDS cases have got the infection through blood transfusion. Since there is a worrying increase in the number of HIV blood donors in some areas, more efforts are required by the authorities and the blood banks to bring this percentage down further, to almost zero, taking into account the possibility of some infected blood being passed on through the window period (due to limitations of the existing serological tests). The blood banking system would benefit if the emphasis is on improving safe blood services and innovative technologies for better laboratory tests for HIV and other transfusion-transmitted infections, rather than on counselling.

References:
1. NACO Blood Policy 2003. www.nacoonline.org
2. Revised NACO Blood Policy 2007. www.nacoonline.org
3. WHO Blood Safety Guidelines. www.who.org
4. K Prabhakar, ‘Prevalence of HIV-positive status among blood donors in urban India’, International Conference on AIDS, 1996 Jul 7-12; 11: 456 (abstract no. Pub.C.1113).
5. Singh, Bharat et al, ‘Prevalence of HIV & VDRL seropositivity in blood donors of Delhi’, Indian Journal of Medical Research, Sept 2005.

(S N Misra is a public health professional based in Delhi who has worked extensively on HIV/AIDS and reproductive health programmes.)

Infochange News & Features, February 2008