|Year : 2018 | Volume
| Issue : 1 | Page : 21-25
Paradigm shift of high-risk sexual behavior among indian blood donors: A threat to blood recipients
Sadhana Mangwana1, Gajender Nath Gupta2
1 Department of Transfusion Medicine, Sri Balaji Action Medical Institute, New Delhi, India
2 Department of Transfusion Medicine, Santokba Durlabhji Memorial Hospital Cum Medical Research Institute, Jaipur, Rajasthan, India
|Date of Web Publication||5-Apr-2018|
Dr. Sadhana Mangwana
Department of Transfusion Medicine, Sri Balaji Action Medical Institute, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Despite the advances in screening of blood through nucleic acid testing to improve the blood safety, there are chances that blood will be donated during the “window period.” Careful selection of donors is an important and pragmatic risk management strategy to ensure blood safety. Subjects and Methods: The observational study was undertaken in two parts. In the first part, retrospective data of donors attending blood transfusion services of tertiary care center between 2014 and 2016 were collated and analyzed. In the second part, an online survey was conducted to assess the prevalence and awareness among donors. Results: A total of 32,773 donors reported for blood donation, of which 8974 (27.38%) potential donors were deferred. Deferral incidence due to high-risk behaviors increased in 3 years from 2.84% to 9.85% with majority of donors (99.60%) being males. Fifty-two percent of donors were repeat donors while 48% were first-time donors. In the survey, 90% of centers question donors about high-risk behaviors, 58% of centers specifically question about sex history. Fifty percent of seroreactive donors in the first part of the study and 63% of respondents found that donors give a positive history of high-risk behavior at the time of counseling. Discussion and Conclusion: In view of the need for optimization of cost of health-care services and maintaining highest level of transfusion safety, its time to devise new solutions in dealing with potentially risky sexual behaviors. Efforts are also needed to educate the general population to understand potential risks of high-risk behaviors and to promote the self-deferral or confidential unit exclusion.
Keywords: Blood transfusion safety, donor deferral, high-risk behaviors, predonation questionnaires, transfusion-transmitted infections
|How to cite this article:|
Mangwana S, Gupta GN. Paradigm shift of high-risk sexual behavior among indian blood donors: A threat to blood recipients. Glob J Transfus Med 2018;3:21-5
|How to cite this URL:|
Mangwana S, Gupta GN. Paradigm shift of high-risk sexual behavior among indian blood donors: A threat to blood recipients. Glob J Transfus Med [serial online] 2018 [cited 2018 Apr 26];3:21-5. Available from: http://www.gjtmonline.com/text.asp?2018/3/1/21/229336
| Introduction|| |
In spite of all precautions and improved methods of detection of transfusion-transmitted infections (TTIs), small residual risk remains. Transfusion recipients are susceptible to receiving contaminated blood if blood donation is made within “window period.”, During HIV/AIDS crisis of the early 1980s, bans preventing men having sex with men (MSM) from donating blood were introduced in many parts of the world.
According to annual SHOT report 2015, morbidity risks due to TTIs were 0.08/100,000 components issued and mortality risks were 0.04/100, 000 components issued. As per the Annual National AIDS Control Organization report 2015–2016, HIV prevalence in Indian adults (15–49 years) is estimated at 0.26% with slightly high in males (0.30%) than in females (0.22%) which is showing a steady decline from estimated 0.38% in 2001–2003 to 0.26% in 2015. HIV prevalence in difference risk groups in India portray concentrated epidemic – like situations. As per integrated behavioral and biological surveillance, HIV prevalence in female sex workers is recorded at 2.2%, in MSM at 4.3%, and among injecting drug users (IDUs) at 9.9% which are considered as classical high-risk groups.
Despite, the introduction of nucleic acid testing (NAT) for blood donation since 1999, there is data available in the literature showing the presence of transfusion-transmitted viruses in the general population. Thus, careful selection of donors is an important and pragmatic risk management strategy to ensure blood safety. Blood transfusion services around the world are using universal TTIs and strict donor deferral policies to refuse certain individual to donate blood temporarily or permanently. Proper screening and selection of blood donors are crucial factor for reducing the risk of transmission of viral diseases and upgrading the overall safety of donated blood inventory.
Studies have shown that despite all these measures, majority of serious risk factors related to behaviors of donors are not picked up by objective evaluation and verification through questionnaires and interview. The donor deferral system is highly reliant on donors understanding and honesty. The system would be meaningless if donors do not disclose their risk behaviors truthfully, being “noncompliant.” An Australian study reported noncompliance rate among donors as 1.65% for any one of the eight TTI risk-related deferrable categories  while in the USA, nondisclosure prevalence is reported as 1.9% among nine deferrable categories.
To date, most noncompliance studies have focused on MSM and IDU in Western countries. To the best of our knowledge, no Indian study has reported on sexual behavior among blood donors and blood safety. To fill the knowledge gap, this observational study was undertaken to determine the prevalence and trends of high risk behaviors (e.g. premarital sex, multiple sex partners, and commercial sex) by general population groups particularly floating population and younger age groups, and to explore the possibilities for improving the present blood donors screening procedures, importance of education of general population, and implementing blood donor self-deferral to reduce the risk of TTIs.
| Subjects and Methods|| |
Screening of blood donors includes providing education and informative material and investigating each donor about possible risk behavior through the use of questionnaire and interview. The physician examining the donor qualifies him or her as eligible for donation or defers the donor. All the successful blood donations are tested for marker of TTIs.
This observational study was undertaken in two parts.
In the first part of the study, donors attending blood transfusion services of a tertiary care centre in the capital city were included. Retrospective data from January 2014 to December 2016 were collated and analyzed. All the donors were routinely given bilingual educational material along with the donor forms. Donors were advised to read the educational material before filling the forms and to understand risk behaviors. Donors were advised to be accurate and honest in answering the questionnaire. All the donors were screened in accordance with the rules laid down in Drugs and Cosmetic Act, 1940. Donors giving a history of extramarital, multiple partners or if found to have some risk behavior were suggested not to donate blood. Various reasons for deferral were noted along with “high-risk behaviors” deferral. These data were part of data submitted to State AIDS Control Society on monthly basis. Positive history during counseling of seroreactive donors was also noted in the year 2016. Statistical analysis was done using Student's t-test. P < 0.001 was considered statistically significant.
In the second part of the study, an online survey was conducted among the transfusion medicine specialists across the country to assess the prevalence and awareness among donors. Following questions were asked in the survey:
- In donor questionnaires, are donors specifically asked about multiple partners relations?
- Are donors questioned about high-risk behavior?
- Do donors respond honestly to such questions?
- What is deferral incidence for high-risk behaviors in the center?
- During counseling for HIV, HBV, or HCV reactive donors, do donors give a positive history of high-risk behavior?
- What are the age groups of donors with high-risk behaviors?
- Any change of trends observed at your center regarding high-risk deferral?
- Is there any change in trends of high-risk behaviors between male and female donors?
- Do you provide educational material to donors for their awareness about high-risk behaviors before filling donor questionnaire?
- Is there an option of confidential unit exclusion or self-deferral at your center?
At the end of the survey, data were compiled and analyzed.
| Results|| |
A total of 32,773 donors were reported for blood donation at tertiary care, blood transfusion services between 2014 and 2016, of which 8974 (27.38%) potential donors were deferred due to various reasons, namely, anemia, underage and underweight, medical/surgical reasons and others such as intake of alcohol, medications. Analysis of data revealed a rising incidence of deferrals due to high-risk behaviors in 3 years from 2.84% (73) through 3.36% (103) to 9.85% (329) in 2016 [Chart 1] which is statistically highly significant (P< 0.001). Age being an important determinant of sexual behavior, study subjects were analyzed according to age in both sets of study. Within various age group distribution, highest number of deferrals due to high-risk behaviors were found in <25 years of age (55%) with nearly 95% of high-risk deferrals in <35 years of the age group in 2015 and 2016 [Table 1]. Of total 505 high-risk deferrals, majority (99.60%) were male donors except two females (0.40%) who gave a history of premarital sex or multiple partner sex or commercial sex. All were replacement donors. Fifty-two percent of donors in this group were repeat donors while 48% were first-time donors.
During counseling of seroreactive donors of HIV, HBV, HCV, and syphilis, nearly 50% of seroreactive donors gave a history of high-risk behaviors which was not revealed at the time of donor questionnaires and donor interviews during screening before qualifying them as eligible for donation.
A total of 96 respondents participated in the online survey conducted across the country. Certain questions were skipped by few respondents leading to variations. In the survey, it was found that though donors are questioned about high-risk behaviors in nearly 90% (86 of 96 respondents) of blood centers, only 58% of centers (56 of 96 respondents) specifically ask about multiple partners or premarital sex history, and defer them. Although education material to donors for their awareness is provided by 76% respondents (70 of 92 respondents), only 38% respondents (36 of 94 respondents) found donors responding honestly to such questions. Eighty-three percent respondents (70 of 84 respondents) found deferral due to high-risk behaviors as <5%, with majority (53%; 48 of 90 respondents) found no change in trends in their centers and 22% respondents (20 of 90 respondents) found increased trends of high-risk deferrals. In terms of age group distribution, 53% responses (50 of 94 respondents) were in the age group <30 years and rest 47% respondents (44 of 94 respondents) found deferrals between 30 and 50 years of age groups. Regarding change in trends of high-risk behaviors between the two genders, 46% of responses (42 of 90 respondents) found no change, 42% respondents (38 of 90 respondents) found increasing trends in males with more than 4% respondents (4 of 90 respondents) found increasing trends in females.
Although the option of confidential unit exclusion or self-deferral exists in 64% of blood centers, still qualified donors do not disclose their high-risk behaviors during donor interviews. Sixty-three percent of respondents found that donors give a positive history of high-risk behavior at the time of counseling for their seroreactivity of HIV, HBV, or HCV.
| Discussion|| |
Recent decades have witnessed the advances in screening of blood through NAT to improve the blood safety, yet there are chances that blood will be donated during the “window period.” Due to this limitation, predonation questionnaires and interviews are used to defer the potential donors whose donations are judged disproportionately risky. Although potential donors are trusted to answer truthfully a range of questions, answers to which may lead to their selection or deferral, but studies have shown that donors generally do not read through the deferral questionnaire in sufficient detail for making an informed decision.
MSM group, IDUs and commercial sex workers and their clients are considered as classical high-risk groups. There are substantial changes in population not belonging to classical high-risk groups. Many people migrate across the country in search of work, particularly from rural to urban which are called “floating population.” Younger age of floating, male population, separation from family members, less education and influence of culture on people's attitudes toward sexuality, larger number of floating population (low-risk group) may participate in high-risk sexual behavior. Reviewing Indian studies regarding donor selection and deferral pattern and prevalence of TTI in Indian scenario, none of the authors acknowledge the contribution of these risk groups.,, The present study clearly showed the rising trend of deferrals due to high-risk behaviors with the majority of donors being young, in their mid 30s.
Because of almost nonexistent sex education in India and lack of knowledge of its direct implication in blood safety, the general population is not completely honest during blood donor screening. This was evident in our study also where 50% donors and 63% respondents found that donors give a positive history only at the time of their counseling for HIV, HBV, HCV, and syphilis seroreactivity. This finding is concordant with previous studies where male donors , and those who had multiple sex partners  were more likely to conceal their deferral behaviors and seriously jeopardizing the health of recipients of blood products., Western studies revealed that 1%–3% of blood donors do not reply sincerely to questions in standard questionnaires used in donor selection procedures.,, The statistically significant difference in our study between men and women having number of sexual partners are in concordance with other surveys that men usually have more sexual partners during their lifetime.
Despite the provision of confidential unit exclusion or self-deferral, nearly 50% of seroreactive donors accepted about not revealing their high-risk behaviors during donor selection process. Urwijitaroon et al. have concluded in their study that donor self-deferral is valid and good tool in reducing the HIV transmission through blood and its implementation should be encouraged during recruiting donors. Literature is being developed around questionnaire and computer-assisted self-interviews (CASI). CASI may reduce the proportion of donors with a history of high-risk behavior by encouraging personal disclosure and self-deferral.
A new insight that our study offers is that conventional indirect questionnaires do not identify potentially infectious donors and direct questions, though leads to increased rate of deferrals, are more effective, similar to the findings by Gimble and Friedman who found that direct positive answers led to increase in donor deferrals while direct questions about high-risk behavior are more effective.
In view of need for optimization of cost of health-care services and maintaining the highest level of transfusion safety, time has come to think of new solutions such as additional questions in the anonymous questionnaire dealing with potentially risky sexual behaviors to improve transfusion safety and sustain transfusion treatment. Predonation questionnaire can be re-formed with questions designed to correlate the most risky forms of (1) exposure, (2) frequency, (3) partners, and (4) travel history to minimise total risk across all population groups. This would give deferral process a broader and more robust combination of methods available to science which would contribute to the public health strategy of reducing sexually transmitted infections in the population as a whole and further increasing blood transfusion safety. Deferral criteria for high-risk sexual behaviors should be reviewed frequently, taking into account changes in disease epidemiology, improvements in available technologies for donation testing and on-going research.
| Conclusion|| |
Despite more relevant questioning, we hope that donors can be trusted and remain motivated to donate blood. Deferral policy would never be effective without donors' compliance and there is plenty of scope for improvement to the deferral policy to make it acceptable and understandable to the potential donors. Role of social scientists is important in developing brief, pertinent, and not so overly intrusive questions. Efforts are also needed to educate the general population to understand potential risks of high-risk behaviors in transfusion safety and to promote the self-deferral or confidential unit exclusion.
Authors would like to acknowledge and thank all the respondents for their contributions in the online survey.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Busch MP, Glynn SA, Stramer SL, Strong DM, Caglioti S, Wright DJ, et al.
Anew strategy for estimating risks of transfusion-transmitted viral infections based on rates of detection of recently infected donors. Transfusion 2005;45:254-64.
Leiss W, Tyshenko M, Krewski D. Men having sex with men donor deferral risk assessment: An analysis using risk management principles. Transfus Med Rev 2008;22:35-57.
Kesby M, Sothern M. Blood, sex and trust: The limits of the population-based risk management paradigm. Health Place 2014;26:21-30.
van den Burg PJ, Vrielink H, Reesink HW. Donor selection: The exclusion of high risk donors? Vox Sang 1998;74 Suppl 2:499-502.
Mahl MA, Hirsch M, Sugg U. Verification of the drug history given by potential blood donors: Results of drug screening that combines hair and urine analysis. Transfusion 2000;40:637-41.
Wong HT, Lee SS, Lee CK, Chan DP. Failure of self-disclosure of deferrable risk behaviors associated with transfusion-transmissible infections in blood donors. Transfusion 2015;55:2175-83.
Lucky TT, Seed CR, Waller D, Lee JF, McDonald A, Wand H, et al.
Understanding noncompliance with selective donor deferral criteria for high-risk behaviors in Australian blood donors. Transfusion 2014;54:1739-49.
Williams AE, Thomson RA, Schreiber GB, Watanabe K, Bethel J, Lo A, et al.
Estimates of infectious disease risk factors in US blood donors. Retrovirus Epidemiology Donor Study. JAMA 1997;277:967-72.
Malik V. Drugs and Cosmetic Act 1940. 16th
ed. Lucknow: Eastern Book Company; 2003. p. 279-303.
Cai R, Richardus JH, Looman CW, de Vlas SJ. Trends in high-risk sexual behaviors among general population groups in China: A systematic review. PLoS One 2013;8:e79320.
Shrivastava M, Shah N, Navaid S, Agarwal K, Sharma G. Blood donor selection and deferral pattern as an important tool for blood safety in a tertiary care hospital. Asian J Transfus Sci 2016;10:122-6.
] [Full text]
Chandra T, Rizvi SN, Agarwal D. Decreasing prevalence of transfusion transmitted infection in Indian scenario. ScientificWorldJournal 2014;2014:173939.
Saha S, Muddegowda PH, Ramachandran T, Jeyakumar MJ, Datla P. Transfusion transmitted infection – An update in India. Natl J Lab Med 2015;4:77-82.
Lee CK, Lee KC, Lin CK, Lee SS. Donors' perspectives on self-deferral of men having sex with men from blood donation. Transfusion 2013;53:2441-8.
Rugege-Hakiza SE, Glynn SA, Hutching ST, Bethel J, Nass CC, McEntire RL, et al
. Retrovirus Epidemiology Donor Study I(REDS I). Do blood donors read and understand screening educational materials? Transfusion 2003;43:1075-83.
Miskulin M, Puntaric D, Miskulin I, Atalic B, Dijanic T. Sexual behaviour of Croatian blood donors as a threat to the health of blood recipients. Blood Transfus 2011;9:407-12.
Stigum H, Bosnes V, Ørjasaeter H, Heier HE, Magnus P. Risk behavior in Norwegian blood donors. Transfusion 2001;41:1480-5.
Jukic I, Balija M, Mihaljevic I, Grgicevic D. Blood donors self exclusion. Vox Sang 2000;78:334.
Damesyn MA, Glynn SA, Schreiber GB, Ownby HE, Bethel J, Fridey J, et al.
Behavioral and infectious disease risks in young blood donors: Implications for recruitment. Transfusion 2003;43:1596-603.
Urwijitaroon Y, Barusrux S, Romphruk A, Puapairoj C, Pakote L. Reducing the risk of HIV transmission through blood transfusion by donor self-deferral. Southeast Asian J Trop Med Public Health 1996;27:452-6.
Gimble JG, Friedman LI. Effects of oral donor questioning about high-risk behaviors for human immunodeficiency virus infection. Transfusion 1992;32:446-9.