Issue Contents    Blood safety Success stories Reducing HIV transmission Strategies for safe blood Donating safe blood Key points Avoiding unsafe donations Screening blood Reducing blood transfusions What is hepatitis B? Education and counselling Safe blood and safer sex Fears about giving blood Public education Before donating blood One-to-one counselling Information for blood donors After donating blood Keeping up commitment Staying safer Counselling blood donors Testing positive Young donors Other HIV testing options Training activities Towards better counselling Keeping confidences Assessing personal risk News Resources

In this issue   Strategies for safe blood Page 2 and 3 Safe blood and safer sex Page 4 and 5 Income generation Page 6 and 7

Strategies for safe blood

Receiving an HIV-infected blood transfusion carries more than a 95 per cent risk of HIV transmission. AIDS Action explains how blood can be made safe.

Donating safe blood 
The best way to ensure that donated blood is free from infection is to encourage donation by people who are: 
 

	unpaid and willing to donate blood voluntarily, responsibly and regularly
	at low risk of HIV and other infections transmitted by blood
	healthy and fully grown in order not to affect their own health, and not pregnant or anaemic, or suffering from any infections
	informed about the tests to be done on their donated blood, including HIV Schools, universities, church groups, community centres and workplaces provide opportunities for educating and recruiting people at low risk of HIV. Public education and sensitive counselling can help people to decide not to give blood if they feel they have been at risk (self-exclusion).

Avoiding unsafe donations

Key points Blood transfusion services use three main strategies to reduce the risk of transfusing infected blood:    minimising the number of HIV-infected blood donations by recruiting and counselling voluntary unpaid donors who are at low risk of HIV testing (screening) all donated blood for HIV and other infections transmitted by blood and safely disposing of infected blood reducing the number of blood and blood product transfusions.  Blood transfusion services are developing these strategies by: setting up a donor selection process; training staff in education and counselling skills; providing a regular supply of equipment for collecting, screening and storing blood; using blood transfusion guidelines; and ensuring quality control.

Screening blood
All donated blood needs to be tested for the presence of infections that are transmitted by blood: HIV, hepatitis B and syphilis. Tests for hepatitis C, Chagas' disease and malaria may be carried out, depending on local disease prevalence and national policy. Blood giving unclear or positive test results for any of these conditions should not be used and be safely disposed of, by incineration, for example. Occasionally a person whose blood tests HIV negative does in fact have HIV. This is usually because of the 'window period'. HIV tests do not detect HIV itself but antibodies produced by the immune system in response to infection with the virus. However; it can take up to three months for these antibodies to be produced.

During the window period an HIV antibody test will produce a negative result even though HIV is present in the blood and may be transmitted. It is therefore very important for anyone who has had possibly risky activity during the past three months to be advised not to give blood. HIV test kits used by blood collection services must be of high quality and the instructions followed exactly. The test used depends on local hospital or national recommendations but it needs to identify all possible HIV infections. This means that the test must be highly sensitive, meaning that it has a low number of false negatives (blood testing negative which is in fact positive). If a blood bank is testing at least 40 blood samples each day an ELISA test will be the most cost effective. If less than 40 blood samples are tested a reliable simple/rapid HIV assay will be more cost effective than an ELISA test.

However, highly sensitive tests can produce false positive results (blood testing positive which is in fact negative). Therefore a positive result does not necessarily mean that the person is infected with HIV People should not be informed of their results after only one positive test result. A second blood sample must be tested. Ideally the test needs to be a different test. It does not need to be a Western blot test but should be done independently of the first test and accurately checked. People should be informed of their HIV infection only if the results of both tests are positive, and if counselling and follow-up support are available.

Reducing blood transfusions
Despite rigorous HIV screening procedures, a few infected blood units may go undetected. It is important to reduce the number of transfusions to the minimum to keep the risk of infecting patients as low as possible and to save costs and blood product use. Blood transfusion guidelines can help prevent over-use of blood products. For example, in rural Tanzania, staff at district, mission and referral hospitals were trained to use guidelines including: 
 

	precise indications for prescribing transfusions to children, pregnant women and other adults with severe anaemia; to patients with acute blood loss; and during, before and after operations
	using blood substitutes where possible such as saline, for example to replace the amount of fluid in circulation after a haemorrhage
	using the patient's pre-collected own blood when surgery is planned
	not using a single unit transfusion of blood as a 'tonic' (often used for 'topping up' blood when someone is weak from anaemia or after an operation).

The project also recommends the following strategies:
 

	setting up a blood transfusion committee to monitor blood use
	regular continuing education and supervision on using guidelines
	clinic meetings where blood transfusions can be discussed by staff
	ensuring that staff provide clear reasons when prescribing blood transfusions on a request form.

Most importantly, illnesses and conditions requiring blood transfusions need to be better prevented. In developing countries most blood transfusions are given to children and women for anaemia or pregnancy complications. Community health care programmes need to provide treatment for malaria and worms for pregnant women and vulnerable children, and to improve nutrition, water supply and sanitation.

With Thanks to Dr Jean Emmanuel, Chief: Blood Safety Unit, WHO; Dr Robert Beal, Interim Director; Blood Dept, IFRCRC; Mr David Mvere, Technical Director; RK Shamu, National Blood Transfusion Service, Zimbabwe; Dr Zarina Bharucha, Head, Dept Transfusion Medicine, Tata Memorial Hospital, Bombay, India.

Source for Reducing blood transfusions: TANESA Project, PO Box 434, Mwanza, Tanzania.

What is hepatitis B? All blood should be screened for hepatitis B, a viral illness which can affect the liver. The infection can be symptomless, but tiredness, yellowing of skin and eyes and loss of appetite are common. Most people recover completely from the early acute infection without treatment, but 10 per cent develop chronic hepatitis, remain infectious to others and may develop liver disease which can lead to death.  The virus can be spread by saliva as well as other body fluids. Common transmission routes are: from an infected mother to her baby before or during birth; during unprotected sex with an infected partner; through an infected blood transfusion; through intimate contact with an infected person, such as through sharing toothbrushes or razors; and by contaminated injecting equipment.  A blood testis the only way to know if someone is infected with hepatitis B. People carrying the virus need education about caring for themselves, such as limiting their intake of alcohol, and preventing transmission by not sharing toothbrushes or razors, and having safer sex. In some countries children are now routinely vaccinated against the hepatitis B, as well as close family members of people with chronic hepatitis. Blood may also screened for hepatitis C, a more recently discovered form of the virus which is transmitted mainly by blood and causes chronic disease in most people infected.

Safe blood and safer sex

Education and counselling for donors not only contribute to making the blood supply safe, but also to promoting safer sexual behaviour.

Public education
Basic information is provided in leaflets, newspaper articles and television or radio advertisements. Donors can be recruited during campaigns or talks at church groups or schools. Messages should emphasise the positive reasons for giving blood, including stories about lives saved with blood transfusions. Education should also highlight the serious need for people to be responsible donors who do not put patients at risk of HIV or other infections.

Before donating blood
When people come to the blood collection centre or mobile van, it is helpful to give a talk or show a video to small groups about the counselling and blood collection process. 

The key messages are: 
 

	what happens when you decide to give blood
	why regular safe donations are needed
	your donated blood is tested for HIV and other infections
	basic facts about HIV and HIV prevention
	your confidentiality is guaranteed
	the importance of deciding not to donate blood if you think you may have HIV or another infection (self-exclusion)
	where to go for counselling and HIV testing, if you wish.

One-to-one counselling 
Ideally each potential donor should have a one-to-one talk with a trained health worker before blood is collected. Staff need to be able to provide accurate information, ask and answer questions sensitively, and refer people to other sources of support.

People wanting to give blood may not have seriously considered that they may have HIV infection. However, it is also very important that people are discouraged from using blood services as testing centres. The counsellor or nurse should check that the person understands how HIV can be transmitted and explain which tests will be done and why, and what the window period is (see page 3). He or she should also explain that blood may not be used for a number of health reasons, including anaemia or syphilis, which can be cured. 

Donors need to know why personal questions, for example about their sexual activity and injecting drug use, are necessary. Discussing these issues helps people to decide whether they should donate blood or if they should exclude themselves because they may have been at risk of HIV 

The Namibian transfusion service found that potential donors had difficulty filling in a 'self-exclusion' questionnaire on their own. Now a trained nurse goes through it with each person and answers any questions. The questionnaire lists activities which exclude the person from donating blood, such as ear and skin piercing, tattoos or traditional skin incisions, any past sexually transmitted infection or common HIV-related symptoms such as night sweat, swollen glands or persistent diarrhoea.

In Honduras the Red Cross National Blood Programme provides pre-test counselling for voluntary blood donors. Leaflets contain information about HIV and the importance of not donating if the person has engaged in activities associated with high risk of infection. Each potential donor is asked to read the brochure. A nurse encourages questions and checks that the information has been understood. The nurse then asks specific questions about sexual behaviour such as all forms of unprotected sex including sex with other men and any history of sexually transmitted diseases. When  this counselling session was introduced in 1991, HIV prevalence among blood donors dropped from 0.38 per cent in 1990 to 0.19 per cent a year later, even though overall numbers of Hondurans with HIV continued to increase. If they do give blood, donors also need to decide whether they wish to know their HIV test results. However, as explained on page 3, this option should only be given if a second test is possible, and counselling and support services are available.

Fears about giving blood  Good systems of confidentiality need to be developed and clearly explained to donors. There is no risk of infection because a new needle and syringe are used for each person. Many donors have given blood over 50 times, up to four times a year; without any harm to their health. Before taking blood, a simple test is performed on a drop of blood taken from a finger prick to find out if the person is anaemic. A local anaesthetic is applied to the skin to make sure that giving blood is not painful, and the donor does not have to watch the procedure. Giving blood can mean life itself for a patient. and even the busiest people find time to donate. Adapted from Fiji Red Cross leaflet.

Information for blood donors   Your name will not be used at the blood bank. Instead we use your mother's unmarried name, your birthplace and your date of birth You will be given a code number which is used on all your records and blood samples. You will be asked some questions about your health to make sure that giving blood will not harm you. You will be asked questions about your private life to ensure that our test results accurate. A sample of your blood will be taken by finger pricking and tested to make sure you have enough blood to spare for a donation.  If so, we will draw your blood. Afterwards we will ask you to rest for a few minutes, take some refreshment to replace the fluids you have lost and take some iron pills to help your body replace the donated blood quickly. The blood you have donated will be tested for hepatitis and HIV viruses.  The results of these tests will be available to you (and no-one else) in two weeks if you choose to know them; Please do not give blood if:   in the last six months you have had sex with someone other than your regular partner; or in the last year you have had: an injection except at a hospital or clinic  skin scarring or cutting by traditional healer a surgical operation; or you have ever had hepatitis (jaundice causing yellow coloured eyes)  you are pregnant, have had malaria or a sexually transmitted infection. Please do:   if you have given blood before and it has been found safe  when three months have passed since your last donation. Adapted from Uganda Blood Transfusion Service information leaflet

Testing positive

Providing counselling for donors who test HIV positive poses key challenges for blood services and counselling groups.

Ideally, people who may be HIV positive should be encouraged not to give blood. However, if the person decides to give blood, they should be given the option of knowing their results. 

They should only be informed if two test results are positive and follow-up counselling and support are available. After talking with a counsellor, people may decide not to give blood but may also want to be referred for an HIV test. Many blood services are trying to link up with NGOs and hospital counselling services.

In 1993, Zimbabwe's blood service reviewed its notification systems after some donors expressed anxieties about confidentiality, especially in relation to HIV, and numbers of adult donors were declining. In the past, people were referred to their doctors, but many donors either did not have a doctor or were reluctant to discuss HIV or syphilis infection with them. 

Now, donors with positive test results for HIV, syphilis or hepatitis are informed by mail that they have an unspecified infection, but are offered counselling and follow-up at an organisation or doctor of their choice (who are also sent letters explaining the situation).

However, NGOs which provide counselling have difficulties in following up donors. In Zimbabwe some NGOs reported that less than half of the people referred to them came for counselling. Common reasons included: people's unwillingness to go to the local 'AIDS centre'; fears about which infection they had, or that they had HIV; worries about being referred to a counsellor whom they already knew personally; difficulties in travelling to the counselling centre during its opening hours; and problems with the postal service.

HIV counselling services often receive referrals for other blood infections, such as syphilis or hepatitis, but counsellors may not have enough information on these illnesses.

Young donors
In many countries school age donors are recruited because they are at low risk. It may be best only to recruit students who are legally adults, who therefore can consent to being tested and to receiving their test results without their parents' permission. Some blood services invite parents to approve the participation of their children, although there is still debate about whether to involve parents in counselling if the young person tests HIV positive. It may be more difficult to confidentially inform and support young people who test HIV positive, especially if they are at school, and if other students are becoming regular donors. Counselling services and blood transfusion centres need to have a policy on recruiting young donors, and counselling them if they are diagnosed HIV positive.

Other HIV testing options
Individuals who are worried that they have HIV often use blood collection services in order to find out their HIV status, rather than to donate blood. This increases the risk of an unsafe blood supply. Independent counselling and testing services help the blood supply to become safer, by making sure that people who want an HIV test can obtain one.

With thanks to Dr S Kalibala, UNAIDS and Mr David Mvere, NBTS, Zimbabwe.

Counselling organisations can help the blood transfusion service by:    encouraging head teachers or employers to allow enough time for pre-donation education and counselling, and post-donation counselling and support  educating the blood service staff, head teachers and employers about HIV to make sure that confidentiality is respected and discrimination does not occur Blood services can hell) counsellors by:   organising adequate pre-donation counselling before taking blood, to help people decide not to give blood if they have engaged in risky activities, or to encourage them to return for counselling if they are notified of possible positive results  ensuring that, if the first HIV test is positive, a second test is carried out and is positive. before informing someone that they have HIV  making sure that referral information is passed to the counselling service before it is mailed to the donor so that the counsellor has full information and time to prepare making sure that the donor information contains information about the advantages of knowing results, Effective counselling Wherever possible, the same person should do the pre-donation and post-donation counselling, before referring. Pre-donation counselling should include talking about what it means for a person to know their HIV status. Blood donors should know that they will be referred if their blood cannot be used, because of other infections, malaria or anaemia and not only HIV. Counsellors need information about infections such as hepatitis and syphilis, in local languages, and to know where to refer people for treatment.  Donors need to understand the meaning of an unclear or false positive result.

Towards better counselling

Keeping confidences
This training exercise aims to help counsellors think about the importance of trust and what might happen if someone's test results are made public. People's greatest concern about giving blood is that their confidentiality will be broken. Confidentiality is essential both to protect people's privacy and help them to feel safe about discussing their personal experiences.

1. Introduce the exercise by raising the issue of confidentiality. Remind the group that people feel more able to discuss personal issues and feelings if they trust that the counsellor will not tell anyone else without their permission. 

2. Split the group into pairs. Ask each person to think of someone they trust and write down ten words describing them, such as friendly, close, and honest.

3. Ask each pair to read out their words to the larger group and write them on a large sheet of paper, noting common words.

4. Split the group into smaller groups of three or four people to discuss the following questions: What do you need to say and do when you are counselling someone to help them have confidence in you? What do you need to do to enable them to keep trusting you? What might happen when confidentiality is broken? What are the benefits of maintaining confidentiality? Invite one person from each small group to report back to everyone.

5. Then give each small group a situation (two examples below), and ask them to discuss their reactions and feelings about being in that position.
   
   You have been diagnosed with HIV During counselling the counsellor promised that he was not going to tell anyone about your diagnosis without your consent Three days later you receive a phone call from a friend who wanted to confirm the news that you had HIV Your friend has heard this from your counsellor.
   
   You work in a factory and the blood collection team arrives. While you are doing the questionnaire you mention to the nurse that you were treated for a sexually transmitted infection four months ago. Your blood is not collected. Later a friend mentions to you that the person next in the blood donation queue saw your form and is telling all your work colleagues that you have AIDS.
   
   Is this situation likely to happen? Why might it happen? How would it make you feel? What would you do or say in that situation? As counsellors. how would you prevent it from happening? 

Source: Mr T R Makoni, National Blood Donor Counselling Co-ordinator, NBTS Zimbabwe.


Assessing personal risk

This activity helps counsellors to think about how they handle risk in their own lives, and increase their understanding of why other people take risks and their feelings about this. Before deciding to take an HIV test people need time to think about what it may mean to discover they have HIV Many people feel anxious about discussing their personal risk of HIV (often for the first time) and are worried about being judged.

1. Invite participants to consider the following on their own for a few minutes:
   
   'Think back on your own life and identify any occasion when you took a risk - related to sex and relationships, to work or to money, for example. It may have been a small risk or a big one that was very important to you at the time.' 

	What factors influenced your decision to take a risk?
	What were your feelings at the time?
	What was the result of taking that risk?
	Do you generally take risks?
	How do you view risk taking in others? How does risk taking among your friends affect you?
	How does this affect your attitude towards the risk of HIV?

It may be useful to write these questions down.

2. After a few minutes ask everyone to choose a partner and share as much of their situation as they wish. Each person should talk for a few minutes and then listen to the partner's story.

3. Invite everyone to join the full circle. Encourage them to explore links between how people deal with risk and ways in which it may affect their responses to HIV/AIDS. It may be useful to make the following points:

	We often feel that it is all right to take risks if they turn out well. But we tend to blame others if they take risks and things go wrong.
	We are generally much less harsh in judging ourselves than we are in judging others. Is this fair?
	We are all taking risks all the time.

4. Then invite people to link this discussion with their counselling work. How can they introduce the subject of risky sexual behaviour without being judgemental? How can this be linked to information about safer sex and reducing the risk of HIV infection?

Source: Working with uncertainty, published by FPA England. 

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