A Ubesie, I Emodi, A Ikefuna
blood donations, blood transfusion, hiv, screening, sickle cell anaemia
A Ubesie, I Emodi, A Ikefuna. High Incidence of Transfusion-Related HIV Infection in Nigeria. The Internet Journal of Hematology. 2009 Volume 7 Number 1.
There is a high incidence of transfusion related HIV infection in Nigeria. This was evident in our pilot study that indicated that the incidence was 1.2% in a teaching hospital in Enugu. In this article, we discuss several possible reasons for the high incidence of transfusion related HIV infections in the Enugu hospital. Firstly, most donors were paid. There was no structured questionnaire to identify populations at risk and to increase self-awareness of the risk of HIV infection. Even if a donor were concerned about having a HIV infection, there was no mechanism for self-deferral. Donated blood was screened only by an ELISA, a test that usually does not detect HIV if contracted within 90 days prior to testing. To control transfusion related HIV infection, the National Blood Transfusion Service (NBTS) was established in 2005, and a National Blood Policy was developed in 2006. Seventeen blood transfusion centers have been set up with support from the private sector, the United States Presidential Emergency Plan for AIDS Relief (PEPFAR), the Safe Blood for Africa (SFA) and the Center for Disease Control (CDC). The goals were: 1) to actively change attitudes to encourage voluntary non-paid donations; 2) to develop and use questionnaires to identify individuals and populations at risk for HIV and to increase self-awareness of the risk for HIV; 3) to introduce mechanisms for self-deferral; 4) to screen blood with antigen testing in addition to the ELISA to detect new HIV infections contracted within16 days prior to testing. An ELISA alone only detects HIV contracted 90 days prior to donation. Despite the regulations introduced by the NTBS, the incidence of HIV infected blood in blood banks is still high. There are multiple reasons for the continued high incidence of transfusion related HIV infections in Nigeria, which includes high endemic incidence of HIV. Another reason is that most donors are still being paid. In teaching hospitals in Nigeria in 2009, about 75% of donors are still paid for donations. The guidelines outlined by NTBS have not been widely implemented. There are an insufficient number of established safe transfusion centers to meet the country’s need for safe blood. Although the government administers public health, the private sector accounts for about 70% of all the health facilities in the country. According to the Nigeria National Blood Transfusion Service, more than 80% of blood collected and transfused in Nigerian hospitals is not properly screened. The donor deferral option has not been widely implemented. The ELISA is still the only test used to screen donated blood for HIV. Unfortunately, there is a lack of political will to regulate adequately the screening of donors for infections
A high incidence of transfusion related HIV infection has been reported in Nigeria1,2. The incidence of HIV due to transfusions given to children with sickle cell anemia was found to be 1.8% in a teaching hospital in Zaria, Nigeria 1. Our preliminary study described below indicates that the incidence of transfusion related HIV infection in the University of Nigeria Teaching Hospital (UNTH) in Enugu was 1.2%.
The incidence of transfusion related HIV infection has to be considered in the context of the prevalence of HIV in Nigeria3-5. The HIV incidence among blood donors in the city of Kaduna was noted to be 2.8%.3. The adult HIV prevalence rate in Nigeria, the largest country in sub-Saharan Africa, was 4.6% in 20085.
The most common sources of HIV infection in Nigeria adult population are heterosexual intercourse and through mother-to-child-transmission (MTCT) in children6. However, transfusion related HIV infection is a known a risk factor7,8.
A Preliminary Study
We have conducted a retroactive study on the incidence of transfusion related HIV infection in children with sickle cell disorders (SCA) who had been transfused since birth. The study was carried out in the Sickle Cell Clinic of the Department of Paediatrics of the University of Nigeria Teaching Hospital (UNTH) in Enugu. A total of 69 children with SCA were studied, 40 males and 29 females. Age ranged from 18 month to 18 years. More than half of the subjects (52%) were aged 13 -18 years. The subjects had received a total of 169 transfusions.
Interviews were conducted to rule out a source of HIV infection other than blood transfusions under conditions that ensured privacy and gained confidence to reveal sensitive information.
The children were tested for HIV using HIV SPOT TEST9, a rapid test for the detection of antibodies to HIV-1 and HIV-2 in serum or plasma. The sensitivity of the test was 100% and specificity 99.9%9. The blood samples that tested positive to this rapid test were retested with Western blot analysis. There were no discordant sera.
Two of the older children tested positive for HIV, but all other children tested negative. Interviews with all children revealed no evidence of consensual sex or sexual abuse or exposure to contaminated sharp objects. These children had never lived or travelled to other regions at which they might have received transfusions.
Based on these data, the incidence of HIV was 1.2% (2/169 transfusions). However, since the 2 children who contracted HIV were at least 13 years old, sexual contact could not be ruled out. The 2 children who supposedly contracted HIV had not been previously tested for HIV. Therefore, our study of SCA children does not conclusively document that the observed HIV positivity was due to tainted transfusions. Nevertheless, the 1.2% incidence of transfusion related HIV infections is consistent with previously reported incidence of 1.8% of transfusion related HIV infection in SCA patients1 as well as other studies 2,10. Therefore, the incidence of transfusion related HIV infection continues to be extremely high.
Blood given to the SCA children was collected, processed and screened at the University of Nigeria Teaching Hospital in Enugu. Most donors were paid for their donations since about 62.3% of the blood given to the children was obtained from paid donors. Potential donors were not asked to fill out a structured questionnaire about risk factors for HIV. Therefore, donors with a high risk for HIV were not identified. In addition, a sensitive screening process was not in place that might have increased donor self-awareness of the risk for HIV. There was no option for self-deferral. Therefore, there was no mechanism for donors, who suspected that their blood might be infected, to choose face-saving self-deferral.
Donated blood was screened for HIV with an Enzyme Linked Immunosorbent Assay (ELISA). During the time frame of the study, 90 of a total of 1,510 units of donated were discarded due to positive ELISA tests. Therefore, the ELISA detected HIV in about 6% of donated blood that reflected the endemic incidence of HIV. However, a major limitation of ELISA testing is that it would not detect HIV contracted during a 3 month period prior to the donation
Efforts to reduce transfusion related HIV infection in Nigeria since 2005
In order to improve blood safety and reduce transfusion transmissible infections, Nigeria established the National Blood Transfusion Service (NBTS) in 200511 and the National Blood Policy in 200612. From 2006 till now, 17 blood transfusion centers13 have been set up in the country with support from the private sectors, the United States Presidential Emergency Plan for AIDS Relief (PEPFAR) through Safe Blood for Africa (SFA) and the Center for Disease Control (CDC).14
The NBTS established regulations for reducing transfusion related HIV. The following are examples of these regulations. Before each donation, qualified staff should establish that prospective donors are in good health and not at risk for having HIV. Standardized questionnaires should also be used to identify high risk donors. Prospective donors with high risk behaviours should be given the opportunity for self deferral. Donors who are unable to demonstrate an understanding of high risk behaviours should be deferred. Both an ELISA and p-antigen testing should be carried out to shorten the window period between contraction and detection of HIV from 90 days to about 16 days15,16.
The following was implemented to encourage non-paid donations. Donor motivation and mobilization should be promoted through extensive awareness programs, such as organized donor drives at community levels, schools, churches and mosques. Public awareness should be created using information/education/communication (IEC) materials, public campaigns, print and electronic media, jingles, billboards, posters and other methods.12
Incidence of transfusion related HIV infection despite the efforts of the NTBS
Despite the regulations introduced by the NTBS, the risk of HIV infections due to transfusions is still high and is still a major public health issue in Nigeria. There are multiple reasons for the continued high incidence of transfusion related HIV infections in Nigeria that includes the high endemic incidence of HIV17,18.
The guidelines outlined by NTBS have not been widely implemented. Most donors are still being paid. Since 2006, 90 to 95% of donors in Nigeria are still being paid for donations19. A recent disturbing report revealed that unhealthy individuals were still being allowed to donate blood and seek payment to offset poverty.20
Sensitive and organized screening and questionnaires are not being used. The donor deferral option has not been widely implemented. There are an insufficient number of established safe transfusion centers to meet the country’s need for safe bloods.11 Therefore, blood is collected, screened and administered by hospital based transfusion centers.21 The standard of care in processing blood varies at different hospitals. There is a lack of a blood system infrastructures and shortage of skilled professionals.22
Although public health is administered by the government, the private sector accounts for about 70% of all the health facilities in the country15. Some of these private health facilities have no standard at all that ensures blood safety. According to the Nigeria National Blood Transfusion Service, more than 80% of blood collected and transfused in Nigerian hospitals is not properly screened23.
The sole reliance on ELISA testing was inadequate for screening blood from #8220;high risk” donors since new infections contracted 90 days prior to testing would not have been detected. Odaibo
Lack of political has complicated the situation. Health funding appears not to be a priority of Nigerian government. The health sector is poorly funded. This situation has become worse due to frequent sectarian crises and the AIDS epidemic that has overwhelmed the health system. Additionally, there is also the problem of dilapidated health infrastructure especially at the primary and secondary tiers of the health system.
Examples of successful reduction of transfusion-related HIV infection that could serve role models for addressing this problem in Nigeria
Transfusion related HIV infection was markedly reduced in South Africa from 0.17% in 1999-2000 to 0.08% in 2001 to 200225. The endemic incidence of HIV in South Africa at that time was high and up to 11.4%.26 The reduction in transfusion-related HIV was due to a new donor selection and education policy.25 The new policy included the following. 1) The new policy that closed donor clinics in areas where HIV prevalence was high. 2) Initiating programs to encourage young people to donate and to promote repeat donations. 3) Developing education programs for staff and donors to identify high risk patients. 4) Obtaining information using structural donor interviews and direct questioning to help identify high risk donors. 5) A mechanism for rejection based on universally accepted criteria (males having sex with males, injection drug abuse, recent sexually transmitted diseases, sex with prostitutes, heterosexual exposure to multiple partners, casual sex, and sexual assault)25. 6) Adopting additional criteria to defer donors with a history of sexual assault in the prior 12 months, a history of having more than 1 sexual partner, or having casual sex in the prior 6 months.25
Prevention of transfusion related HIV infection has been most effective in the USA, Canada and other developed countries. Only 1 per 1.25 million transfusions in developed nations like United States. Stramer
What could be done in Nigeria to reduce transfusion related infections?
The South African model is a cost effective strategy that could be adopted in Nigeria. It would be important to use a standardized questionnaire that identifies high risk donors. Blood should not be obtained from high-risk donors. Blood donations in communities with high prevalence of HIV should be discouraged. Self-deferral options should be implemented. In addition to screening blood with ELISA, antigen and NAT screening should be implemented. However, the current budget limitation may limit the expansion of laboratory screening.
Campaigns that encourage voluntary non-remunerated donors should be intensified using the media, opinion leaders, traditional and religious leaders, government officials and organized civil society. The health system in the country should be strengthened to recruit well-trained and motivated health care workers, repair and upgrade health facilities as well as repair and replace obsolete equipment.